DISEASES OF THE SKIN 



CROCKER 



DISEASES OF THE SKIN 



THEIR 



DESCRIPTION, PATHOLOGY, DIAGNOSIS, AND 
TREATMENT 



SPECIAL REFERENCE TO THE SKIN ERUPTIONS OF CHILDREN 

AND 
AN ANALYSIS OF FIFTEEN THOUSAND CASES OF SKIN DISEASE 



H. RADC LI FFE-C ROCKER 

M. D. (Lond.), F. R. C. P. 

Physician for Diseases of the Skin in University College Hospital; Honorary Member 

of the American Dermatological Society; Membre Correspondant Etranger de 

la Societd Francaise de Derjnatologie; Correspondierendes Mitglied der 

Wiener dermatologischen Gesellschaft ; Socio Onorario della 

Societa, Italiana di Der?natologia e Sifilografia; Late 

Physician to the East London Hospitalfor Children; 

Examiner in Medicine, Apothecaries' Hall, 

London 



THIRD EDITION, REVISED AND ENLARQEfi . „ 



WITH FOUR PLATES AND ONE HUNDRED AND TWELVE 
ILLUSTRATIONS 



PHILADELPHIA 

BLAKISTON'S SON & CO, 

1012 WALNUT STREET 
1905 



THE LIBRARY OF 
CONGRESS, 

Two Copies Received 

JAN 23 1903 

ft Copyright Entry 

ClASS ' L XXc. No. 
S I t $ 
COPY B. 



X> 



^ 



Copyright, 1903, 

BY 
P. BLAKISTON'S SON & CO. 



THE MERSHON COMPANY PRESS, 
RAHWAY, N. J. 



/ 



PREFACE TO THE THIRD EDITION 



The exigencies of practice and other engagements, as well 
as the enormous literature produced by numerous workers in 
dermatology in all civilized Countries, have rendered the prepa- 
ration of this edition a long and arduous task, and the Second 
Edition has been out of print for the last three years. 

It has been my earnest endeavor to bring the work up to 
date. Many of the articles have been entirely rewritten, and 
all have been thoroughly revised, and often in great part recast ; 
nevertheless the book has grown considerably, but as my aim 
has been to make it as clinically complete as possible, the 
< rowth has been almost entirely on this side. The original 
| ^n of the work has, however, been preserved, so that the 
student can without trouble at first confine his attention to the 
most important features of the commonest diseases, while he 
can use it as a work of reference as his practical knowledge in- 
creases (vide p. 31). 

A few of the names of the diseases have been changed from 
the last edition, such as Dermatitis herpetiformis for Hydroa 
herpetiformis, Lichen acuminatus instead of Pityriasis rubra 
pilaris, etc.; but this has been almost entirely in the interests of 
uniformity of nomenclature, these being the names which have 
met with the most general acceptance. A very few other 
changes have been made for other reasons. 

The following are among the new articles: Acrodermatitis 
perstans, Persistent balanitis, Cheilitis exfoliativa, Lichen annu- 
latus, Erythema serpens and Erysipeloid, Erythema elevatum 
diutinum, " Gayle " in man, X-Ray dermatitis, Toxin Serum 
Eruptions, Bronzing of the Skin in Diabetes, Keratolysis ex- 
foliativa congenita, Porokeratosis, Mai de Meleda, Lupus mar- 
ginatus, Granuloma annulare, Granuloma inguinale tropicum, 
Granuloma pyogenicum, Sarcoid, Mortimer's Malady; Pseudo- 
xanthoma elasticum, Leukaemia and Pseudo-leukaemia cutis, 




6 ' PREFACE TO THE THIRD EDITION. 

Chloroma, Endothelioma capitis, Veld sore; Hydrocystoma, 
Milium congenitale, x\cne keratosa, Acne necrotisans, Acne 
agminata, Folliclis, Alopecia seborrhoica, Alopecia cicatrisata, 
Ulerythema ophryogenes, Folliculitis decalvans, Lentigo senilis, 
Blastomycosis hominis, etc. For most of the above long list, 
which is not complete, the articles have been short, but there 
have been many others, such as Erythema scarlatiniforme 
recidivans, Parakeratosis variegata (Lichen variegatus), etc., 
which had only a brief mention in the previous edition, but have 
now had, on account of our increased experience and knowl- 
edge of them, to be expanded into comparatively important 
articles. 

With the view of helping my co-workers, numerous refer- 
ences have been given, especially choosing those which best 
opened up the literature of the subject. References to colored 
illustrations of most forms of skin diseases have also been given, 
largely, as is natural, to my own Atlas; but where the particular 
form of disease was not illustrated there, or where there was 
an especially good plate in another atlas or article, attention 
has been drawn to it, so that the reader may be enabled to help 
himself to realize the description in the text. With this object 
also a colored plate of the principal syphilids has been intro- 
duced, as their diagnosis can be made from a sample of the 
eruption, better than is the case in most non-specific eruptions 
where distribution, generally, plays so important a part. Two 
plates have also been given of the Ringworm Fungi in accord- 
ance with the most modern views. 

In conclusion, I have to thank Mr. George Pernet, not only 
for assisting me in reading the proofs and other help while the 
book has been passing through the press, but for cordial and 
indefatigable assistance in sifting the literature of the subject, 
in preparing the microscopical sections for the new illustrations, 
and for writing the section in the Appendix on the Staining of 
Micro-organisms. My thanks are also due to Mr. Harold 
Wilson, B. Sc, Head Dispenser at University College Hospital, 
for reading the proofs of the formulary at the end, to prevent 
pharmaceutical errors being passed over. 

121 Harley Street, December 21, 1902. 



CORRIGENDA. 



Page 565. For Fig. 27, read Fig. 27A. 

" 574. Line 9 from bottom, for papillomatous, Tva^papillomatosa. 

640. " 16 from bottom, for Stockholm, read Ulm. 

" 640. " 12 from bottom, for Schurigii, read Schurigius 

(Schurig). 

" 900. Note, for Santon, read Sauton, 

" 904. " " Syder, read Lyder. 



CONTENTS, 



PART I. 

GENERAL. 

PAGE 

Semeiology, 33 

Objective Symptoms, 33 

Primary Lesions, 33 

Secondary Lesions, 40 

Special Lesions, • . .44 

General Symptoms, . .45 

Subjective Symptoms, ... 48 

Etiology, 50 

General Hygienic Conditions, 50 

Race and Family Constitutional Conditions, .... 54 

Personal Constitutional Conditions, 55 

Pathology, 64 

Diagnosis, 68 

Treatment, 72 

Internal Treatment, 72 

Local Treatment, .83 

Classification. 96 

PART II. 
SPECIAL. 
CLASS I. 

hyperemia:— congestions. 

Erythema, 108 

Erythema Hypercemicum, 109 

" Simplex, 109 

" Ab Igne, no 

" Pernio, in 

" Intertrigo, .113 

" Lseve, 114 

" Paratrimma, .115 

,l Fugax, . . . 115 

" Urticans, . . . ■ 115 

" Roseola, 115 

9 



io CONTENTS. 

PAGE 

Idiopathic Roseola, 116 

Symptomatic Roseola, 116 

Erythema Scarlatiniforme, . . . . . . . . . 117 

" " Recidivans, 120 

Deciduous Skin, or Keratolysis, 123 

CLASS II. 

EXUDA TIONES—INFLAMMA TIONS. 

Erythema Exudativum, 125 

Erythema Multiforme, 126 

" or Herpes Iris, 133 

" Nodosum, .......... 137 

Elevatum Diutinum, 141 

Peliosis Rheumatica, 144 

Pellagra 149 

Acrodynia, or Epidemic Erythema, 154 

Urticaria, 155 

Urticaria Pigmentosa, 171 

Prurigo, 178 

Eczema, 186 

Eczema Circumscriptum (?) Parasiticum, 234 

Dermatitis Repens, 235 

Acrodermatitis Perstans, 236 

Diseases due to Pus Cocci, 239 

Impetigo, 241 

Impetigo Contagiosa, 242 

" Bullosa, 244 

" Gyrata, 244 

of Bockhart, 244 

Ecthyma, . 249 

Pemphigus Neonatorum, 250 

Contagiosus, 253 

Furunculus, 254 

Carbunculus, ............ 260 

Herpes, 264 

Herpes Zoster, 265 

Herpes Facialis 281 

" Progenitalis, .......... 284 

Persistent Balanitis, 286 

Zoster Atypicus, 287 

Bullous Eruptions, 287 

Pompholyx, 288 

Epidermolysis Bullosa Hereditaria, or Congenital Traumatic Pem- 
phigus, ........ v. . . 292 

Pemphigus, 295 

Hydroa, 325 



COXTEXTS. ii 

PAGE 

Dermatitis Herpetiformis 326 

" Vacciniformis seu ^stivalis, 341 

" Recurrens, 346 

Acrodermatitis Pustulosa Hiemalis 350 

Impetigo Herpetiformis, 351 

Psoriasis, 354 

Pityriasis Rubra, 389 

Dermatitis Exfoliativa Neonatorum, 399 

Pityriasis Rosea, 405 

Epidemic Exfoliative Dermatitis, 410 

Cheilitis Exfoliativa, 413 

Lichen, 414 

Lichen Acuminatus, 416 

" Planus, ........... 425 

" Variegatus, 443 

" Scrofulosus, 446 

" Pilaris, seu Spinulosus 452 

Annularis, 456 

Dermatitis, 457 

Dermatitis Traumatica, 457 

" Calorica, . 458 

" due to the X-Rays, 458 

" Venenata, 460 

Artef acta (Feigned Eruptions), 467 

Medicamentosa, 469 

Animal Poisons, 506 

Dissection Wounds, .......... 507 

Post-mortem Pustule, . 508 

Erythema Serpens, 508 

Erysipeloid 508 

Gayle, ............. 509 

Equinia 510 

Pustula Maligna, 513 

Vaccination Rashes, 516 

Sphacelodermia, ' 527 

Symmetrical Gangrene, or Raynaud's Disease, .... 528 
not due to Raynaud's Disease, . . .531 

Hysterical Gangrene, 532 

Zoster Atypicus Gangrsenosus et Hystericus 534 

Dermatitis Gangrenosa Infantum, 535 

Single Gangrenous Patches, 539 

Multiple Gangrene in Adults, ........ 541 

Diabetic Gangrene, 543 

Phagedena Tropica, 544 

CLASS III. 

HsEMORRHA GIsE—H^MQRRHA GES. 

Purpura, 548 



12 CONTENTS. 

CLASS IV. 
HYPER TROPHIC— HYPER TROPHIES. 

PAGE 

Ichthyosis 559 

Keratolysis Exfoliativa Congenita, 572 

Keratoses, 573 

Verruca, 575 

Clavois, 582 

Cornu Cutaneum, 584 

Callositas, 586 

Keratosis Palmae et Plantse, 587 

Keratosis Pilaris, 591 

Porokeratosis, 59* 

Keratosis Nigricans (Papillaris) 596 

" Vegetans (Follicularis), 604 

" Follicularis Contagiosa, 610 

Angiokeratoma, 612 

SCLERODERMIA, 615 

Diffuse Symmetrical Sclerodermia, 616 

Circumscribed Sclerodermia, 628 

Mixed Sclerodermia, 638 

Sclerema Neonatorum, 640 

Edema Neonatorum 643 

Elephantiasis, 645 

CLASS V. 

ANOMALIES OF PIGMENTATION. 

Lentigo, 659 

Senilis, 662 

Chloasma, 663 

Argyria 671 

Albinism, 674 

Leukodermia, 675 

CLASS VI. 

A TROPHIC- A TROPHIES. 

Atrophoderma, 680 

Xerodermia Pigmentosa, 681 

Atrophodermia Albida, 691 

Diffuse Idiopathic Atrophy, 692 

Kraurosis, 696 

Symptomatic Atrophy 696 

Degenerative Symptomatic Atrophy 697 

Atrophia Cutis Senilis 697 

Striae et Maculae Atrophicae, 698 

Multiple, Benign, Tumor-like New Growths, . . . . ■ . 702 

Glossy Skin, 703 



CONTENTS. 



*3 



PAGE 

Perforating Ulcer of the Foot, 705 

Morvan's Disease, 707 

Ainhum, . 716 

CLASS VII. 

NEUROSES— SENSORY DISEASES. 

Hyperesthesia, , 714 

Dermatalgia, 715 

Causalgia, 715 

Erythromelalgia, 715 

Pruritus, 717 

Anaesthesia, 726 

CLASS VIII. 

NEOPLASM ATA— NEW GROWTHS. 

Molluscum Contagiosum, 729 

Xanthoma, 737 

Xanthoma Diabeticorum, 750 

Colloid Degeneration of the Skin, 755 

Pseudo-Colloid of Lips, 758 

Tuberculosis of the Skin, 759 

Lupus Vulgaris, . 762 

" Verrucosus, 797 

" Marginatus, 801 

Miliary Tuberculosis of the Skin, 802 

Acute Tuberculous Ulcer of the Skin, . , . . , . . 804 

Scrofulodermia, 806 

Tuberculous Tumors, 808 

Erythema Induratum 811 

Lupus Erythematosus, 815 

" Telangiectodes Disseminatus, 833 

Syphilis, 835 

Lepra, 900 

Rhinoscleroma, 927 

Embryogenic Growths, or Nsevi, 932 

Keloid, 933 

Fibroma, 944 

Neuroma, 954 

Myoma ' 955 

Nsevus Pigmentosus, 859 

" Vascularis, .......... 962 

Telangiectasis, 967 

Angioma Serpiginosum, ......... 970 

Lymphangiectasis and Lymphangiomata, 973 

Lymphangiectodes, 974 

Lymphangioma Tuberosum Multiplex, 978 



14 CONTENTS. 

PAGE 

Epithelioma Adenoides Cysticum, 982 

Adenoma Sebaceum 9 85 

Carcinoma Cutis, , .991 

Epithelioma, gg^ 

Paget's Disease of the Nipple, 100 ^ 

Rodent Ulcer, 1009 

Sarcoma Cutis, 2019 

Mycosis Fungoides, 10 ^ 2 

Yaws, I057 

Verruga Peruana, I0 67 

Furunculus Orientalis, . 1069 

Granuloma Inguinale Tropicum, 1076 

Papilloma of the Skin, 1079 

Granuloma Pyogenicum (Botryomycosis Hominis), . . .1081 

Granuloma Annulare, 1082 

CLASS IX. 
MORBI APPENDICIUM— DISEASES OF THE APPENDAGES. 

A. Diseases of the Sweat Glands, 1087 

Hyperidrosis, 1087 

Bromidrosis 1092 

Chromidrosis 1093 

Colored Sweating, 1097 

Phosphorescent Sweat, 1099 

Uridrosis, 1099 

Anidrosis, 1100 

Miliaria, 1101 

Hidrocystoma, 1107 

Tumors of the Sweat Glands, 1109 

B. Diseases of the Sebaceous Glands, 11 10 

Seborrhea, 11 10 

Seborrheides, . . .1119 

Seborrheic Dermatitis, 11 19 

Sebaceous Cysts, . ; 1124 

Multiple Atheromatous Cysts, 1126 

Dermoid Cysts, 1127 

Follicular Disease of the Scalp, . ^ 11 28 

Milium, » 1129 

" Congenitale, 1131 

Hypertrophy of the Sebaceous Glands, . . . .1131 

Comedones, 1133 

Grouped Comedones, 1134 

Acne 1136 

Acne Vulgaris, 1137 

" Rosacea, . 1147 



CONTENTS. I5 

PAGE 

Acne Acuminata, 1149 

" Varioliformis, . 1155 

" Scrofulosorum, 11 59 

" Keratosa, 1160 

" Agminata, . . . . 1164 

Folliclis, 1167 

C. Diseases of the Hair Follicles, 11 71 

Concretions on the Hair, 1171 

Lepothrix, 1171 

Piedra, 1175 

Chignon Fungus 11 76 

Tinea Nodosa, 1176 

Plica, . . . . . . . . . . . .1178 

Hirsuties, .1179 

Atrophy of the Hair, 1187 

Fragilitas Crinium, 1187 

Trichorrhexis Nodosa, 1188 

End Atrophy, 1191 

Monilithrix, 1191 

Canities, 1193 

Discoloration of the Hair, . . . . . . . 1199 

Alopecia, 1200 

" Seborrhoica, 1204 

" Areata 1209 

" Cicatrisata, 1232 

Ulerythema Ophryogenes, 1234 

Folliculitis, 1235 

Sycosis, 1237 

Dermatitis Papillaris Capillitii, 1243 

Folliculitis Decalvans, 1246 

Depilating Folliculitis of the Limbs, . . . ... . 1247 

Tuberculous Folliculitis, 1248 

D. Diseases of the Nails, 1248 

Pterygium, . 1249 

Onychia, 1250 

Onychauxis, *.. . . " . . . 1251 

Onychomycosis, 1252 

Shedding of the Nails, 1252 

Atrophy, 1254 

Onychorrhexis, . 1254 

Ridged Nails, 1255 

Separation of the Nails, 1255 

White Nails, 1256 

Spoon Nails, 1257 

Tylosis of the Matrix, . . . . . . . . 1257 

Reedy Nails, 1260 

Transverse Furrows, 1267 



16 CONTENTS. 

CLASS X. 
HYPHOMYCETIC PARASITES. 

PAGE 

Diseases due to Fungi, I2 64 

Favus, I2 6s 

Tinea Trichophytina, 1279 

" Tonsurans, 1280 

" Circinata, 1309 

" Barbae, 1315 

" Ciliorum, 1320 

Onychomycosis, 1321 

Tinea Imbricata, 1323 

•' Versicolor, 1327 

Erythrasma, 1333 

Pinta Disease, 1335 

Actinomycosis of the Skin 1330 

Mycetoma, 1346 

Blastomycosis, 1350 

CLASS XI. 

ANIMAL PARASITES OF THE SKIN. 

Animal Parasites, 1357 

Scabies, 1358 

Demodex Folliculorum, 1369 

Ixodes, 1371 

Leptus Autumnalis, 1372 

Pediculosis 1373 

Pediculus Capitis, 1374 

" Corporis, 1377 

" Pubis, 1381 

Pulex Penetrans 1384 

" Irritans, 1385 

Cimex Lectularius, 1386 

Culex Pipiens, 1386 

CEstrus, 1387 

Larva Migrans of Gastrophilus, 1388 

Craw-Craw, 1389 

Dracunculus Medinensis, 1392 

Cysticercus Cellulosae Cutis, 1396 

Echinococcus Hydatid, ........ 1397 

Distoma Hepaticum, 1397 

Bilharzia Hematobia, 1397 

Ankylostoma Larvae, 1397 

APPENDIX 1399 

Analysis of Fifteen Thousand Cases, 1399 

Clinical Examination and Staining of Bacilli and Fungi, . . 1406 

Natural Mineral Waters and Spas, 1410 

Formulae, 14*7 

INDEX, . 1441 



LIST OF ILLUSTRATIONS. 



PAGE 

Plates I. and II. Syphilids, ....... 846-47 

III. and IV. Ringworm Fungi, 1282-83 

FIGURE 

i. General view of the skin and its appendages, . . . .21 

2. General view of the epidermis, showing also the nerve termi- 

nations, 22 

3. The prickle cells of the rete mucosum, 23 

4. The papillae of the skin, 24 

5. The corium and blood vessels, 25 

6. The lymphatic channels of the papillary layer and epidermis, . 26 

7. Tactile corpuscles (Biesiadecki), 27 

8. Pacinian corpuscle, 28 

9. Diagram of the lines of cleavage of the skin, .... 46 

10. Erythema tuberculatum, ........ 131 

11. Urticaria pigmentosa, . 176 

12. Mast cells, 177 

13. Chronic eczema of palm, superficial portion, .... 212 

14. Chronic eczema of palm, deep portion, ..... 212 

15. Micrococci of impetigo contagiosa, 246 

16. Herpes zoster areas, 267 

17. Herpes zoster areas, 269 

18. Pompholyx, ........... 292 

19. Pemphigus bulla, 319 

20. Pemphigus vegetans, ......... 320 

21. Psoriasis papule, . 362 

22. Psoriasis papule, 370 

23. Pityriasis rubra, 402 

24. Lichen planus, recent papule, 436 

25. Lichen planus, old papule, 437 

26. Lichen pilaris, 454 

27. Iodid eruption, 492 

27. (a) Ichthyosis hystrix, . 565 

28. Keratosis nigricans: skin of abdomen, e 603 

29. Keratosis nigricans: papillary growth, 603 

30. Sclerodactylia skiagram, 620 

31. Circumscribed sclerodermia patch, 634 

32. Circumscribed sclerodermia patch, blood-vessel in, . . . 634 

33. Xerodermia pigmentosa, tumor of, 690 

34. Molluscum contagiosum, tumor with single acinus, . .731 

35. Molluscum contagiosum, small tumor, 736 

2 17 



18 LIST OF ILLUSTRATIONS. 

FIGURE PAGE 

36. Molluscum contagiosum, section of hair follicle, . . . 737 

37. Xanthoma plaque, 746 

38. Xanthoma tuberosum, . 747 

39. Xanthoma diabeticorum, low power, . . . , . 753 

40. Xanthoma diabeticorum, high power, 754 

41. Lupus vulgaris, low power, 777 

42. Lupus vulgaris, high power, 778 

43. Curette for lupus 788 

44. Vidal's knife, . 788 

45. Pick's lupus scarifier, 789 

46. Lupus verrucosus, 800 

47. Syphilitic macula, 849 

48. Papulo-squamous syphilid, 851 

49. Circinate squamous syphilid, ....... 855 

50. Lenticular syphilid, 857 

51. Large follicular syphilid 858 

52. Small follicular syphilid, 86c 

53. Recent scar keloid, , 94c 

54. Fibroma, 952 

55. Adenoma sebaceum, 989 

56. Pseudo-psorosperms in Paget's disease, ico6 

57. Rodent ulcer " wart," low power, 1015 

58. Rodent ulcer, high power, 1017 

59. Nevo-carcinoma pigmented cells, 1021 

60. Myeloid cell sarcoma 1024 

61. Mycosis fungoides, 1048 

62. Papillary growth like granuloma inguinale tropicum, . . 1078 

63. Granuloma annulare, nape papule, 1085 

64. Granuloma annulare, knuckle, 1086 

65. Normal sweat gland, ......... 1088 

66. Normal sebaceous gland, 1112 

67. Hypertrophied sebaceous gland, 1132 

68. Clover's acne presser, . 1145 

69. Kaposi's acne lancet, 1146 

70. Acne agminata, . . 1166 

71. Normal hair and sebaceous gland, 1172 

72. Longitudinal section of a hair root, 11 73 

73. Lepothrix from scrotum, 11 74 

74. Lepothrix from axilla, n 75 

75. Tinea nodosa, 1177 

76. Pseudo-nodules on hair from internal root sheath, . . . 1178 

77. Needle holder for electrolysis, 1183 

78. Split hair, 1187 

79. Trichorrhexis nodosa 1188 

80. End atrophy of the hair, 1191 

81. Moniliform hair, 1193 

82. Hair in process of pigmentation, 1195 



LIST OF ILLUSTRATIONS. 



19 



84. 

85. 
86. 
87. 
88. 

89. 
90. 
91. 
92. 
93- 
94- 
95- 
96. 

97- 
98. 
99. 

100. 

101. 

102. 

103. 

104. 

105. 

106. 

107. 

108. 

109. 

no. 

III. 



FIGURE 

83. Ringed hairs, .... 

Band form of alopecia areata, 
Hair stumps of alopecia areata, 
Section of scalp in alopecia areata, 
Longitudinal section of normal nail, 
Transverse section of normal nail, 
Hair shaft and bulb from favus, 
Fungus elements from a favus scutulum, 
Microsporon Audouini, from tinea circinata, 
Trichophyton megalosporon, 
Tinea cruris, 

Mycelium from tinea circinata tropica. 
Hair from beard in tinea barbae, 
Trichophyton endothrix of nails, 
Onchomycosis from tinea tropica, 
Microsporon furfur, 
Actinomyces, or ray fungus, 
Blastomyces, 
Acarus, female, 



Acarus, male, 
Acarus, larva, 
Acarus, burrow, 
Demodex folliculorum, 
Leptus autumnalis larva, 
Ova of pediculi capitis, 
Male pediculus capitis, 
Female pediculus vestimenti, 
Pediculus pubis, 
Larva of gastrophilus, 



PAGE 

1197 
1214 
1216 
1226 
1249 
1250 
1271 
1274 
1310 
1311 
1312 
1314 
1317 
1321 
1322 
133 1 
1343 
1352 
1362 
1363 
1363 
1364 
i37i 
1372 
1375 
1377 
1380 
1380 
1389 




Fig. i is a general diagrammatic view of the skin, after Heitzmann. It 
shows three divisions of the skin, viz., the epidermis or epithelial 
part; the corium or true skin or fibrous part; and the subcutaneous 
tissue, panniculus adiposus or fat laver. In the upper part of the 
corium, called the papillary layer, are the skin papillse containing 
vessels and nerve terminations and lymph spaces, while the middle 
and deep layers contain the vascular plexuses, the hair follicle, its 
muscle, and sebaceous glands, and the tortuous sweat duct which 
traverses it to reach the sweat coil situated in the fat layer. 




^mmm 




Fig. 2, from Ranvier's " Histology," shows the three principal divisions of 
the epidermis, viz., the horny layer (r), the granular layer (g), and 
the rete Malpighii, the mucous or prickle-cell layer (m). To these 
some add a fourth layer, or stratum lucidum, which lies just above 
g, but it is only a subdivision of the horny layer. The lowest row of 
cells of the rete also are cylindrical and placed perpendicularly, and 
are sometimes called the "palisade layer." This figure also shows 
the nerve terminations in the rete; ;/ is the afferent nerve, b the ter- 
minal nerve bulbs, and / is a cell of Langerhans. 




"■AtZZ 



*X*XA 



V2>02i 



Fig. 3, from Ranvier's " Histology," shows the cells of the rete Malpighii 
more highly magnified in order to demonstrate their prickle-like proc- 
esses, which, at their junction with those of the neighboring cells, 
leave small channels between the cells. 



23 




Fig. 4, also from Ranvier, shows the papillae of the pulp of the finger 
after the epidermis has been detached by soaking in iodized serum: 
P, papillae; v, blood-vessel ; c, papillary ridges. Other views of the 
papillae are exhibited in Fig. 5 and Fig. 7. 



24 



^s 




2.5 ALLS 



Fig. 5, from Ranvier, shows the arrangement of the blood-vessels in the 
papillary layer of the corium: c is the epidermis traversed by a sweat 
channel, s; d is the corium; j# points to the papillae; and v, the arter- 
ial and venous capillaries of the papillae, constituting the superficial 
or papillary plexus. This plexus also supplies the hair follicles and 
a " basket-like " plexus to the sebaceous glands. The drawing only 
shows a part of the other or deep horizontal plexus, which runs at the 
upper border of the subcutaneous tissue, and communicates with the 
superficial plexus by perpendicular vessels. The deep plexus sup- 
plies the sweat coils by means of a delicate plexus, as at v s, gives a 
single loop to the hair papilla and networks for the fat lobules. 



25 









am 



®8B 









%d£&r~ 



Fig. 6. — Staining with gold of all the lymphatic channels of the papillary 
layer and epidermis of a slightly edematous skin (Unna). 



26 




Figs. 7 and 8 are to show the tactile and Pacinian corpuscles. Fig. 7 (Bie- 
siadecki) shows a, a vascular, and b, a nervous papilla; c is a blood- 
vessel; d, a medullated nerve fiber inclosed in a thick nucleated 
sheath; e is a tactile corpuscle; /, transversely divided medullated 
nerve fibers. 



27 







Fig. 8 (Ranvier), Pacinian corpuscle from the mesentery of a cat:*:, cap- 
sules; d, endothelial lines which separate them; n, afferent nerve; 
/, funiculus; m, central club formation; n' , terminal fiber; a, point 
where one of the branches of the terminal fiber is divided into a great 
number of branches terminating in bulbs. The nerve terminations in 
the epidermis are shown in Fig. 2. 



28 



ABBREVIATIONS. 



(Unless otherwise stated). 

" Atlas" or " Author's Atlas" refers to my Folio Atlas of Diseases of 
the Skin, 1896. 

" Brocq " refers to " Traitement des maladies de la peau," second edi- 
tion (1892). 

" Duhring" refers to " Diseases of the Skin," third edition. Only two 
parts of his new work, " Cutaneous Medicine," are published. 

" Tilbury Fox" refers to his " Skin Diseases," third edition. 

" Hebra " refers to the Sydenham Society's translation of Hebra and 
Kaposi's great work on diseases of the skin. 

" Hutchinson " refers to " Lectures on Clinical Surgery," vol. i. (" On 
Certain Rare Diseases of the Skin.") 

" Hutchinson's Archives " refers to the Archives of Surgery. 

" International Atlas " refers to International Atlas of Rare Diseases 
of the Skin. 

" Kaposi-Besnier" or "Kaposi Besuier-Doyon " refers to the second 
French edition (1891), from the third German edition of Kaposi's work. 

" Kaposi " refers to American Translation, 1895. 

" Leloir and Vidal" refers to the " Traite descriptif des maladies de la 
peau " of those authors, of which only three parts have appeared. 

" Monatshefte " refers to the Monatshefte fiir praktische Dermatologie. 

"Schwimmer" refers to " Die neuropathischen Dermatonosen." 

" Ziemssen " refers to " Handbook of Skin Diseases " volume of Ziems- 
sen's Cyclopaedia of the Practice of Medicine. 

" St. Louis Atlas," refers to Atlas of Diseases of the Skin from the 
wax models in the Saint Louis Hospital, Paris, or the English translation 
by Pringle. 



29 



INSTRUCTIONS TO THE STUDENT 



The portions that the student should read at first are the sec- 
tions on semeiology, etiology, pathology, and diagnosis in the 
general part, while in the special part he should confine his at- 
tention to the most common diseases, such as he could see in 
a few attendances at an out-patient clinic, reading at first only 
the description of the typical features of each disease, the 
pathology without the anatomy, and the leading points in the 
diagnosis and treatment. The work is so arranged that he can 
readily do this, and the less important details can be subse- 
quently studied as his clinical experience enlarges. 

The diseases he will want at first are erythema intertrigo, 
erythema scarlatiniforme, erythema exudativum multiforme and 
its special variety nodosum, urticaria, eczema, impetigo con- 
tagiosa, boils and carbuncles, herpes varieties, pemphigus, 
psoriasis, lichen planus, purpura, ichthyosis, elephantiasis, mol- 
luscum contagiosum, lupus vulgaris, lupus erythematosus, 
scrofulodermia, syphilis, keloid, rodent ulcer, pruritus, miliaria, 
seborrhea, comedones, acne vulgaris, acne rosacea, alopecia 
areata, sycosis, the various forms of tinea trichophytina. tinea 
versicolor, scabies, and the varieties of pediculosis. 

It is by attempting too much at first that the student fre- 
quently fails both in examinations and practice, a useless smat- 
tering being often the sole result of his misdirected efforts. On 
the other hand, he should not begin to learn diseases till he has 
mastered the semeiology, which is as necessary as the alphabet 
is as a preliminary to reading. 

{For abbreviations see preceding page.) 



3* 



DISEASES OF THE SKIN 



PART I.— GENERAL. 



SEMEIOLOGY. 

The symptoms of skin disease are objective and subjective, 
and they may be limited to the skin itself, or involve other parts, 
or even the whole organism. 

In some instances the skin disease is the primary event, and 
the general disturbance secondary to it, as in cases of extensive 
and severe skin diseases, which lead to general vital depression, 
febrile disturbance, or marasmus. On the other hand, — and this 
is by far the larger class, — some internal derangement, func- 
tional or organic, as in disturbances of the alimentary canal, the 
uterus and ovaries, the kidneys, etc., leads directly or indirectly 
to the skin disorder. Every departure from health, therefore, 
whether in the skin or elsewhere, must be duly examined into, 
and its relative importance considered. 

OBJECTIVE SYMPTOMS. 

These comprise the elementary lesions of the skin, and are 
divided into primary and secondary. A clear appreciation of the 
exact characters of these lesions is essential for accurate diag- 
nosis. And the omission to master this " ABC " knowledge of 
the subject makes dermatology a sealed book for a large pro- 
portion of the profession. 

PRIMARY LESIONS. 

Maculae. Synonyms. — Spots; Macules; Fr., Taches; Ger., 
Flecke. 

Definition. — Macules are discolorations level with the skin, of 
various sizes, shapes, and tints. 
3 



34 DISEASES OF THE SKIN. 

Thus, their size may be from a pin's point to as large as the 
hand or more; they may be round, oval, or irregular, but most 
are roundish; they may be well or ill denned; less frequently are 
altered in density or consistence; but their most striking and 
variable feature is their color, which is generally some shade of 
red, yellow, or brown. They may, or may not, disappear under 
pressure; may last a short or a long time, or even be permanent; 
and while some have subjective symptoms, most have none. 
They may also be primary or secondary. 

In describing maculae, regard must be paid to their size, color, 
shape, definition, consistence, and changeability under the influ- 
ence of time, pressure, or other conditions, and their subjective 
symptoms and mode of production. 

Their causes are very numerous. They may be due to : 

i. Hyperemia, arterial or venous. This congestive kind of 
macula is red if arterial, bluish-red if venous, and always dis- 
appears under pressure, and when associated, as often happens, 
with some inflammatory swelling, is slightly raised above the 
surface, and although there is fluid exudation from the vessels, 
it is not more than can be soaked up by the cells and tissues of 
the epidermis and corium. The eruption, as a whole, is included 
under some form of erythema, or roseola, the latter term being 
applied to general exanthemata, as in that of typhus or syphilis. 
Another form is the red areola round inflammatory foci. 

2. Extravasation of blood, and blood-coloring matter, into 
the skin gives rise to spots of various sizes and shapes. They 
are unaltered by pressure, are bright or purplish-red at first, 
but undergo bruise-like changes of color as absorption occurs. 
When in the shape of streaks they are called vibices ; when 
punctate, petechiae ; when of larger size, ecchyrnoses. They may 
occur as complications of inflammatory lesions. When blood- 
coloring matter alone escapes, yellowish, orange, or cafe au lait 
colored patches are produced, which are generally due to partial 
mechanical venous stasis, and are common on the legs. 

3. Under both congenital and acquired conditions the vessels 
of the skin may become permanently dilated, or new vessels 
formed. The capillary nevus is an example of the congenital 
form; stellate and other shaped telangiectases exemplify the ac- 
quired form. They may be accompanied by inflammatory or 
other lesions. 



SEME10L0GY. 35 

4. Changes in the pigmentation of the skin, either from excess 
or deficiency, may exhibit themselves in various forms of spots 
or patches, and may be congenital, as in moles, or acquired, as 
in lentigo or chloasma, or the flat form of xanthoma, in which 
there are other changes besides discoloration. They may also 
be secondary to other inflammatory changes, as in the stains left 
by lichen planus, most syphilids, etc. Diffuse pigmentations 
are not generally called maculae, but are spoken of simply as 
discolorations of the skin, as in Addison's disease, malarial 
melanosis, argyria, bile staining, etc. 

From loss of pigment arise the white spots known as vitiligo 
or leukoderma; white spots are also seen in morphea and general 
scleroderma, but here there are other, more important changes, 
besides the loss of pigment. 

Tropho-neurotic conditions also are often associated with 
whiteness of the skin, as in -maculae atrophicae, glossy skin, etc.; 
but in these cases there is diminished volume of the skin also. 

Papulae. Synonyms. — Papules; Pimples; Fr., Papules; Ger., 
Knotchen. 

Definition. — Papules are small elevations of the skin, not ex- 
ceeding a split pea in size, nor visibly containing fluid. 

Papules are always small; a pin's point to a small pea repre- 
sents their extremes in size. Their shape may be round or angu- 
lar at the base, and in elevation convex or lenticular, acutely or 
bluntly conical, or even flat at the top. In color they are some 
shade of red, white, or yellow. They may be situated in the epi- 
dermis or in the corium, and connected with the papillae, sweat, 
or sebaceous glands, or with the hair follicles. In describing 
them, therefore, regard must be paid to their size, shape, color, 
and anatomical position in the skin, and to their mode of pro- 
duction and subjective symptoms. The tendency among the 
careless and ignorant is to make the term " lichen " synonymous 
with a papular eruption; this should be carefully avoided, as it 
always leads to confusion, and when employed without a quali- 
fying term, as in " lichen planus," is utterly meaningless. A 
still more self-deceiving term is " lichenoid," which is only a 
cloak for ignorance. 

Papules, when due to inflammation, may be: acuminate, as in 
papular eczema, or flat and angular, as in lichen planus, and 



3 6 DISEASES OF THE SKIN. 

these may have a central depression; others are caused by ex- 
cessive cornification of the epidermic follicular lining, as in 
keratosis pilaris; or by contraction of the arrectores, as in 
" goose skin," in which the papules are colorless; and according 
to Auspitz, their permanent contraction produces prurigo pap- 
ules. Papules may also be produced by the accumulation of 
sebum, as in milium and comedo; by hemorrhage into hair folli- 
cles, as in purpura papulosa; and in the peculiar process of xan- 
thoma. Some inflammatory papules — c. g., some papular syphil- 
ids — are scaly; others may go on to vesiculation or pustulation, 
as often happens in papular eczema. Papules vary much in 
duration, and may be acute, chronic, or permanent; the last are 
non-inflammatory, as in milium. They may or may not be at- 
tended by itching, which is sometimes very severe. 

Nodulae. Synonyms. — Nodules; Tubercles; Fr., Tubercules; 
Ger., Knoten. 

Definition. — Nodules are solid elevations of the skin, from a 
split pea to a hazelnut in size. 

Nodule is preferable to the older term " tubercle," as this may 
be confused with pathological tubercle. 

The definition requires some qualification, as size is not the 
only criterion in all cases, though it is so as a rule. Thus, on the 
one hand, nodule is employed for the discrete lesions of lupus, 
tertiary syphilis, and leprosy, even when they are smaller than a 
split pea; and on the other, many neoplastic growths of small 
size are called tumors, which from their size alone might be 
called nodules, for authors are not strict in their discrimination 
between a tumor and a nodule. Hence it has been proposed to 
restrict the term to cellular infiltration (granuloma of Virchow) 
in a nodular form in the skin not larger than a hazelnut. Nod- 
ules of this character often go on by peripheral extension and 
coalescence to an infiltration in which the corium is permeated, 
or replaced, by granulation cells, in diffuse instead of nodular 
masses, slightly elevated as a rule, with sharply defined borders, 
and flattish surface. When of inflammatory origin the color is 
usually red or brownish-red, but small tumors may be of any 
color. Their size, shape, color, consistency, and course are the 
points to be specially noticed. 



SEMEIOLOGY. 37 

Tumores. Synonyms. — Tumors; Fr., Tumeurs; Ger., Ge- 
schwiilste. 

Definition. — New growths of all kinds, from a pea and upwards 
in size. 

There is no limit to the size of tumors in an upward direction. 
The shape also is equally variable, though, unless compound, 
they are generally roundish. They are generally, but not al- 
ways, well defined; may be sessile or pedunculated, with broad 
or narrow superficial or deep attachments. They are raised to 
a very variable extent, movable with the skin, or fixed to deeper 
parts, and may, or may not, be attended with itching, tenderness, 
or pain. 

Their causes are very various. As they may take their origin 
from any part of the skin, its vessels or appendages, the color 
may or may not be altered. The chief points to be observed are, 
the size, shape, color, elevation, vascularity, mode and depth of 
attachment, mobility, subjective symptoms, and, where possible, 
the part of the skin in which they originate. 

Vesiculae. Synonyms. — Vesicles; Fr., Vesicules; Ger., Blas- 
chen. 

Definition. — Vesicles are elevations above the surface of the 
skin, from a pin's head to a hemp seed in size, with free con- 
tents of serous fluid. 

Vesicles are produced by elevations of the upper layers of the 
epidermis by fluid, which may be forced upwards from below, 
either by mechanical or inflammatory pressure. They may arise 
directly on the surface, as in miliaria; or on the top of an inflam- 
matory base, diffuse or papular, as in eczema. Their contents 
may be clear, turbid, or more or less blood-stained. They are 
generally tense, but the large ones may be flaccid; most of them 
rupture, as in eczema, but in many the contents are either ab- 
sorbed or dry up without rupturing, as in sudamina or herpes. 
Their shape is, if discrete, roundish at the base and convex or 
acuminate at the top, or they may be pitted, as in the vaccine 
vesicle. They may be quite superficial, as in sudamina, or deep- 
seated, as in lymphangiectodes; consist of one or more cham- 
bers, as in herpes or varicella; be discrete or coalescent. They 



38 DISEASES OF THE SKIN. 

are generally inflammatory, but are not so in sudamina or lym- 
phangiectodes; are usually of short duration, and either rupture, 
or the contents dry up, become absorbed, enlarge into blebs, or 
pass into pustules. Anatomically, they may be situated between 
the horny layers, between the mucous and horny layers, or in 
the mucous layers, w r hile in lymphangiectodes they are in the 
lymphatics of the corium. As a rule they tend to group in va- 
rious ways, may remain discrete or coalesce, and being generally 
acutely inflammatory, are very often attended with burning and 
itching. The points to be observed are their size, color, con- 
tents, base, depth, mode of evolution, course, duration, the sub- 
jective symptoms, and, if the contents are evacuated, the condi- 
tion of the skin beneath. 

Bullae. Synonyms. — Blebs; Fr., Bulles; Ger., Blasen. 

Definition. — Blebs are vesicles which are as large as, or larger 
than, a pea. 

Like vesicles, they are generally formed in the middle and 
deeper layers of the rete, and their roof is formed by the remain- 
ing layers of the epidermis, but sometimes the whole epidermis 
is elevated. 

They vary in size, from a pea to a large hen's Qgg; the smaller 
and medium-sized bullae are generally roundish or oval, but 
when very large, being often formed by several coalescing, they 
are irregular in outline. They have usually tense, strong walls, 
and therefore seldom rupture spontaneously, the contents dry- 
ing up; but they may be flaccid, as in pemphigus foliaceus, and 
rupture early in their development. The contents are usually 
clear, straw-colored, consisting of serum, and therefore alkaline 
and albuminous, but sometimes there is sero-pus, pus, or blood. 
Bullae, as a rule, have no areola unless they contain pus, rising 
abruptly from the healthy skin, but they are usually preceded by 
a transitory redness. Often no special sensation, except that of 
tension in the fully formed bulla, attends them; but occasionally, 
as in dermatitis herpetiformis, there is intense itching. Blebs 
are the prominent symptom in pemphigus, dermatitis herpeti- 
formis, pompholyx, and herpes iris; are frequent in leprosy, 
syphilis, and erysipelas; and may be present occasionally in ery- 
thema exudativum, urticaria, measles, and in vesicular diseases 



SEMEIOLOGY. 39 

such as eczema, herpes, and varicella; in short, they may occur 
as an accident, so to speak, in almost any acute inflammatory 
affection of the skin. 

The points to be observed are their size, shape, contents, du- 
ration, and, after rupture, the condition of the exposed surface. 

Pustulae. Synonyms. — Pustules; Fr., Pustules; Gcr., Pusteln. 

Definition. — Pustules differ from vesicles and blebs only in 
containing pus. 

Pustules sometimes arise directly, but generally develop from 
vesicles or papules, and various intermediate conditions are 
therefore often simultaneously present. They are always of in- 
flammatory origin, and unless blood-stained, of a yellowish 
color, and have, as a rule, a red areola, sometimes with indura- 
tion, as in boils; most of them are round and convex, some- 
times umbilicated, as in variola, but some are pointed, others 
flat and irregular, as in ecthyma; these, and indeed the majority, 
arise in the papillary layer, but they may be formed round the 
sebaceous glands, as in acne; round the hair follicles, as in sy- 
cosis; or deep in the corium, as in boils. Their course is gener- 
ally acute and they usually rupture, the contents concreting into 
a firm crust, yellowish, greenish, or brownish if blood-stained; 
or they may dry up, and the crust is then less discolored, and 
friable. In either case a scar may be left if the process is deep 
enough. Pustules are often painful and tender, sometimes at- 
tended with burning, but seldom with itching. The points to be 
noted are their size, shape, color, mode of evolution, anatomical 
position, base, course, and sequelae. 

Pomphi. Synonyms. — Wheals; Urticse; Fr., Plaques ortiees; 
Ger., Quaddeln. 

Definition. — A wheal may be described as a circumscribed 
edema of the corium, producing a flat elevation of the epidermis 
at that point. 

A wheal may be artificially produced by injecting a drop of 
water underneath the skin. Usually wheals are the result of an- 
gioneurotic irritation, external or internal, leading to the sud- 
den outpouring of serum from the vessels; this is followed im- 



4 o DISEASES OF THE SKIN. 

mediately by a spasmodic contraction of the capillaries. On the 
spasm ceasing, the released capillaries take up the fluid again, 
and the wheal subsides. They are very variable in size, from a 
pin's head to a goose's egg, flatly convex as a rule, but the very 
large discrete ones are hemispherical; if large from coalescence 
only, they then form elevated patches. The outline is irregular, 
often determined by external causes, e. g., scratching. The 
color is usually whitish in the center with a pink areola, or when 
the tension is not so great, rose-red all over, less frequently, 
with an anemic white areola; occasionally they are purple, from 
hemorrhage into them. They are evolved very rapidly, in a 
few minutes or even seconds, and as a rule last only a few hours 
or days, but are occasionally persistent. They may go on to the 
formation of bullae, or leave behind them pigmentation, inflam- 
matory papules, or even large lesions, as in urticaria pigmen- 
tosa. They are always attended with severe tingling or itching, 
are the characteristic lesions of urticaria, but may be produced 
as a local condition, e. g., from the stinging-nettle or rhus 
poison, the bites of insects, etc. The points to be noted are, 
their size, color, mode of evolution, duration, sequelae, and their 
local or constitutional origin. 

SECONDARY LESIONS. 

Squamae. Synonyms. — Scales; Fr., Squames; Gcr., Schuppen* 

Definition. — Scales are dry, laminated exfoliations of the epi- 
dermis. 

Scales may be, and usually are, the result of an inflammation, 
in which proliferation rather than exudation is the main feature. 
Or they may be due to preternatural dryness of the skin, as in 
seborrhea sicca and xeroderma. Or again, they may be the se- 
quel of a previous acute hyperemia, as in erythematous erup- 
tions, especially those of scarlatina and erysipelas, when the 
most superficial layers of the epidermis are thrown off. 

They may be very small and branny, as after measles, or in 
pityriasis rosea, or in dandruff; or very large and thin, as in 
pityriasis rubra; they may be in a single layer, as in eczema 
squamosum; or adherent into crusts, as in psoriasis; silvery, 
white, or gray, as in the last disease; or dirty yellowish-looking, 



SEMEIOLOGY. 41 

as in many syphilids and ichthyosis. They are dry and brittle 
unless mixed with exudation. When due to inflammation they 
are usually on a more or less reddened base, unless in the form 
of desquamative sequela. Their quantity may be very small, or 
they may be shed literally in quarts per diem, as in severe pity- 
riasis rubra. The points to be noted are their size, color, quan- 
tity, being separate or in crusts, their presence as a symptom or 
a sequela of the lesion. 

Crustae. Synonyms. — Crusts; Fr., Croutes; Gcr., Borken, 
Krusten. 

Definition. — Crusts are irregular dried masses of exudation, or 
other effete products of disease. 

Crusts vary much in appearance, according to their amount 
and origin. They may be adherent or loose, according to their 
age and the condition of the surface on which they rest. They 
may be thin and flat, or thick and craggy, according to the quan- 
tity and nature of the exudation from which they originate. 

As a rule, crusts are the result of dried inflammatory exuda- 
tion, consisting mainly of serum, pus, or blood mixed with 
epithelium. 

They may, however, be chiefly composed of fat and epithe- 
lium, as in seborrhea, and are then greasy, light yellow when re- 
cent, dirty yellow or blackish when old; they are flat and ad- 
herent, but can easily be peeled off. Or they may consist of fun- 
gous elements, yellow and powdery, as in favus, or claylike, as 
in tinea imbricata. Inflammatory crusts of serous origin are 
light yellow, friable, and translucent, as in eczema and impetigo 
contagiosa in the serous stage, while the purulent crusts of the 
same diseases are thick, dark, and dirty-looking, and firmer in 
consistence. In ulcerating syphlids they may be in layers, 
very thick, firm, and greenish, while blood-crusts are of a dirty 
red, brownish, or blackish hue. All crusts follow in outline the 
excoriated surface on which they rest, and when the exudation 
is free and thin they are soon thrown or rubbed off, while, when 
it is thick they may get heaped up by the drying of successive 
layers as the ulcer extends, as in the limpet-shell crusts of rupia. 

The points to be noted are their thickness, color, size, con- 
sistence, adherence, composition, and the condition of the sur- 
face beneath them, for which of course their removal is essential. 



42 DISEASES OF THE SKIN. 

Excoriationes. Synonyms. — Excoriations; Fr., Excoriations; 
Ger., Hautabschiirfungen. 

Definition. — Excoriations are lesions in which, as a rule, the 
surface is denuded only as far as the stratum mucosum; they 
heal, therefore, without leaving scars. The shape, depth, and 
extent depend upon their mode of production, which, apart from 
superficial wounds from mechanical causes, is mostly by the 
nails in scratching; hence they are encountered most frequently 
and are most developed in pruritic diseases. The excoriations 
of the nails consist of puncta, which soon get scabbed over, from 
the decapitation of the follicular prominences of the skin; lines 
of scratching, superficial or comparatively deep, in which the 
epidermis is more or less torn up in places; these, when recent, 
are surrounded by an areola, which may be swollen into a wheal, 
and excoriated, soon becoming scab-topped papules developed 
secondarily from the constant irritation of the nails. Other 
lesions, directly or indirectly due to scratching, are ecthymatous 
pustules, eczematous patches, enlargement of the neighboring 
lymphatic glands, and when the pruritus is of long standing, 
thickening and pigmentation of the skin. All these symptoms 
go to make up the " scratched skin " in its highest development, 
but they are not all present except in severe and chronic cases, 
the number and extent depending upon the vigor of the scratch- 
ing. Although this " scratched skin " is really a compound of 
various lesions besides excoriations, the group occurs so fre- 
quently that it may, as a whole, be considered to be a symptom 
of many diseases, such as prurigo, urticaria papulosa of infants, 
pediculi corporis, scabies, etc. The position, extent, and ar- 
rangement of the lesions are of diagnostic importance in a large 
number of instances. 

Rhagades. Synonyms. — Fissures; Fr., Fissures; Gcr., Rhag- 
aden, Hautschrunden. 

Definition. — Rhagades are linear cracks in the skin, whether 
due to injury or disease. 

Fissures are produced in the parts where there is most move- 
ment, whenever, as the result of inflammation or other cause, 
the elasticity of the skin has been impaired. Their most fre- 
quent position is on the palmar and plantar surfaces of the 
hands and feet, the angles of the mouth and anus, and the flex- 
ures generally. They usually occur along the natural lines of 
flexion or other movement, as may be seen on the palms and 
soles in the so-called eczema rimosum, at the angles of the 



SEMEIOLOGY. 



43 



mouth and anus in congenital syphilis, or in chronic eczema of 
the lips; but, of course, any other cause, such as local irritation, 
producing tension, with loss of elasticity, will produce them. 
They are painful on movement, especially when they extend to 
the corium. 

Ulcera. Synonyms. — Ulcers; Fr., Ulceres; Ger., Geschwiire. 

Definition. — Ulcers are losses of substance of the skin, extend- 
ing into the corium and produced by disease. 

The size is quite indefinite; the shape variable, the most com- 
mon being round, but it may be reniform, irregular, or serpigi- 
nous. They may be deep or shallow, with steep or sloping sides 
and smooth or irregular base; the edges may be sharp or 
rounded, everted or undermined; the surface bleeds readily, is 
clean or sloughy, covered with pus or serum only; most crust 
over if left to themselves, but some keep up a continual dis- 
charge of varying amount, which may be offensive or not, and 
is usually grayish or yellowish, but sometimes sanious. Apart 
from injury, they are usually the result of lupus, syphilis, struma, 
lepra, malignant tumors, boils, or carbuncles. Varicose veins 
are a favoring condition for their occurrence on the lower ex- 
tremities, where they are very common. They are generally 
painful, exquisitely tender, and their duration and course are 
very variable, depending upon a variety of conditions; their tend- 
ency, unless malignant or circumstances are unfavorable, is to- 
wards healing, but they always leave a permanent scar. The 
points to be noted are their position, size, shape, depth, edge, 
sides, floor, secretion, and course. 

Cicatrices. Synonyms. — Scars ;Fr., Cicatrices; Ger., Narben. 

Definition. — Scars are connective tissue new formations replac- 
ing losses of substance, which extend as far as the corium. 
Whatever may be the cause of loss of substance, whether injury 
or disease, healing can only take place by cicatrization, in which 
the hairs, glands, and papillae are absent, but there are vessels 
and nerves; the resulting scar varies according to the depth of 
the lesion. 

The lesion need not, however, produce ulceration, as in some 
forms of lupus and syphilis, when the normal skin is infiltrated 



44 



DISEASES OF THE SKIN. 



and replaced by cells, which may undergo absorption, and the 
result is a scar, without any breach of surface; or when the skin 
is over-distended, as in linear albicantes; or when there is pres- 
sure, as in favus, in which the growth of the fungus digs into the 
skin. All these are examples of atrophic scarring, and the cica- 
trix is thin, white, glistening, and pliable. When the ulcer ex- 
tends deeply into the tissues, as in burns, the scar will be con- 
tracted, thickened into bands, and adherent to subjacent tissues, 
and there are intermediate conditions. The scar may also be 
raised much above the surface, from increase of connective 
tissue, and form " hypertrophic scarring," or go on to the con- 
dition known as keloid. They are thus of all shapes, sizes, and 
thicknesses, raised or depressed, in bands, knots, lines, or spots, 
smooth or puckered. Their color is usually whitish and glisten- 
ing when they are old, but they are red at first, and may remain 
so, or become purplish or pigmented. Their red or purple color 
may be due to dilated blood-vessels coursing over them. Scars 
are not often attended with subjective symptoms, but may itch 
or be painful, especially when a nerve twig is implicated in them. 
The history of scars should always be carefully inquired into, 
as, when not due to injury, they are often of great diagnostic 
importance, the great majority being due to lupus, syphilis, or 
struma. The points to be noted are their position, size, shape, 
color, texture, and mobility. 

Stains. Various eruptions leave stains behind them; these 
are generally produced by the escape of blood-coloring matter 
during the inflammatory process. Syphilids are especially 
noted for this, but many others also, as lichen planus, leave very 
dark pigmentation, while exudative erythemata, psoriasis, and 
many others, as a rule, leave only a red mark, which passes off 
in a week or two. 



SPECIAL LESIONS. 

There are a few lesions of special characters, which do not 
come under any of these heads, such as warts, horns, burrows 
of the acarus scabiei, etc., which will be explained in their special 
sections. 



SEMEIOLOGY. 45 



GENERAL SYMPTOMS. 

The several lesions having been examined individually have 
now to be considered collectively. A single group, or separate 
area of disease, is " a patch," while the patches taken altogether 
constitute the eruption. 

Distribution — Cleavage. The arrangement of the lesions in 
the patch, and the relations of the patches to each other, are 
governed to a certain extent by laws; and although we do not 
yet thoroughly understand them, some light has been thrown 
on the subject by the studies of C. Langer * and S. Swerchesky f 
with regard to what is known as the "cleavage" of the skin; 
while O. Simon J has treated the whole subject. 

When a round awl is thrust into the skin, Langer found that 
the skin was split into linear clefts in most parts, though in some 
a triangular or ragged hole was produced, e. g., on the scalp, 
forehead, chin, and epigastrium. This he called " cleavage," 
and it was said to be complete in the first case and incomplete 
in the second; and in the difference depended, he found, upon 
the arrangement of the connective tissue bundles, which in 
complete cleavage ran mainly in one direction, and in incom- 
plete cleavage ran pretty equally in different directions. Fur- 
ther, when the whole body was thus punctured in rows at equi- 
distant intervals, the surface was mapped out into lines which in- 
dicated the general direction of the fibers in each region, and he 
found that these lines of cleavage ran, for the most part, ob- 
liquely to the axis of the trunk, sloping from the spine down- 
wards and forwards, in the direction of the ribs at the upper 
two-thirds, but more horizontally lower down. In the limbs 
they were for the most part transverse to their longitudinal 
axis, and there were sub-variations in different regions, c. g., 
circular girdles at the shoulder. The blood-vessels also were 
found by Tomsa to form circulatory planes where the cleavage 
was uniform, but where it was indefinite, the vascular trunks 

* Langer, " Sitzungsberichte der kais. Akad. d. Wiss.," Wien, 1861, 
Bd. xliv. and xlv. 

+ Annates de Syph. et Derm., July, 1871. 

X " Die Localisation der Hautkrankheiten histologisch und klinisch 
bearbeitet," mit 5 Tafeln. Berlin, 1873. 



4 6 



DISEASES OF THE SKIN. 



were very tortuous, and ran vertically upwards, forming globu- 
lar areas of distribution. This cleavage, or more directly the 
vascular distribution consequent on the cleavage, has been found 




Fig. 9. — Diagram of the lines of cleavage of the skin (Langer). 



to correspond in many respects with the arrangement of the 
groups of individual lesions. These may take various forms, 
of which circles, segments of circles, concentric circles, with or 



SEMEIOLOGY. 47 

without punctate centers, and ellipses are some of the most com- 
mon, while connecting lines of eruption between the papules 
also run in the cleavage direction. 

The vaso-motor centers which preside over different areas are, 
in my belief, an important element in governing the distribution 
of eruptions. One of the most important of these vascular areas 
is that of the head and neck down to just below the clavicle, the 
forearm, back of the hand, and the lower two-thirds of the upper 
arm on the extensor side, sloping down to the lower third on 
the inner side. This distribution is preserved in the great ma- 
jority of cases of xeroderma pigmentosum, and it is usually ac- 
counted for by saying that it is the region exposed to the sun 
and air. But this is not strictly true; the lesions extend beyond 
the exposed part, and an exactly similar distribution may often 
be seen in eczema in adults of both sexes where there has not 
been any exposure either so low in the neck or so high in the 
arms. Another area is in the lower part of the back and upper 
part of the thighs. Many cases of extensive moles have this dis- 
tribution, called sometimes the " bathing-drawers area." Coun- 
ter irritation over the cervical and lumber enlargements, respec- 
tively, often exhibits a distinct influence on inflammatory erup- 
tions in these regions. The part of the cheeks called by Hutch- 
inson the " flush patch " is another such area. These are only 
examples, as the subject cannot be pursued further here. I have 
observed, however, that the area of anesthesia, after cord or sin- 
gle nerve injuries, often corresponds with the distribution of in- 
flammatory and other eruptions, and both neurology and derma- 
tology might give to each other much assistance by the further 
study of these relationships. Dr. H. Head's diagrams of the 
areas of distribution of herpes zoster should also be studied. 

Eruptions may be symmetrical or unsymmetrical, with regard 
to the two halves of the body; unilateral, especially when own- 
ing a direct nervous distribution, as in herpes zoster, some cases 
of morphea, ichthyosis hystrix, and some of the eruptions of 
anesthetic leprosy. Other terms that require explanation are 
" universal," which signifies, not only that every region is 
affected, but that there is no intervening healthy skin between 
the lesions, as in pityriasis rubra; while an eruption may be said 
to be " general " when every region is affected, while there are 



48 DISEASES OF THE SKIN. 

some healthy areas, as in the worst cases of psoriasis. On the 
other hand, an eruption may be " localized " to one or two re- 
gions; it may be " aggregate," i. c, crowded together; or " dis- 
seminate," i. <?., scattered irregularly over the body. Patches or 
lesions may also be "discrete," i. c, separate; or they may be 
" confluent." If in circular patches, or segments of such circles, 
the eruption is called " circinate "; if in rings, " annulate"; or 
if two rings meet and coalesce they are always broken at the 
point of contact, and " gyrate " figures are produced, as may be 
seen in vegetable parasitic eruptions. When a disease creeps 
slowly at one border, clearing up at the older part, it is said to 
be " serpiginous," as in the " serpiginous ulceration " of tertiary 
syphilids; or if the border is very abrupt, it may be called 
" marginate," as in erythema marginatum; while sharply de- 
fined patches are called " circumscribed." Small lesions the size 
of a millet seed are called " miliary," and when the size and 
shape of a split pea, " lenticular." There are many other quali- 
fying terms, but their meaning is obvious. Such are those re- 
lating to the "age" of the patient, c. g., prurigo senilis; the 
" general color " of the rash, c. g., erythema iris, or lichen ruber; 
the " special region " affected, e. g., eczema palmare; the " age " 
of the rash, " acute," " chronic," " transitory." 

Any others in less common use will be explained, if necessary, 
as encountered in the several diseases. 

In this section, therefore, the points to be noted are the ex- 
tent and general arrangement of the eruption, the shape and size 
of the patches, and the relation of the individual lesions to each 
other; their aggregation or otherwise, and the duration of the 
whole rash; its general course, and the age of the patient. 



SUBJECTIVE SYMPTOMS. 

Subjective symptoms may be present or absent, and of all 
grades of intensity. Pain, tenderness, heat, tingling, itching, and 
smarting are the symptoms often met with, chiefly in inflamma- 
tory disorders; and pain is the chief symptom in phlegmonous 
inflammations and new growths of malignant character. The 
most common symptom is itching, which may be very slight or 
severe, and may be due to the direct effect of the lesion, or re- 



SEMEIOLOGY. 49 

flexly neurotic, as in many forms of pruritus. Formication is 
a modification of pruritus, and the sensation of tingling is closely 
allied to it. Anesthesia or loss of sensibility, and hyperesthesia 
or exalted sensibility, are rarely met with in diseases of the 
skin. Hypertrophies, atrophies, hemorrhages, and benign new 
growths are seldom attended with subjective symptoms. 



ETIOLOGY. 

The subject of the causes of cutaneous disease is a complex 
one and must be discussed under several heads. 

A disease of the skin may be symptomatic or idiopathic. It 
may be so entirely symptomatic as not to require separate 
treatment apart from the general condition to which it is due, as 
in the exanthematic eruptions belonging to the acute specific 
diseases, such as scarlatina and measles, or the early erup- 
tions of the chronic specific diseases, such as syphilis and lep- 
rosy, polymorphous erythema, the xanthoma of the diabetic, the 
eruptions of scurvy, etc., or, while it may be due to a general or 
local internal derangement, both the skin and the offending or- 
gan must be treated as in gouty eczema, dyspeptic acne, and the 
like. In idiopathic diseases the departure from health either 
originates in, and is confined in its effects to, the skin itself, or 
appears to be so, as not infrequently the real cause eludes our 
observation. This includes all local diseases, e. g., many hyper- 
trophies and atrophies, and those dependent on external causes 
generally. 

The causes predisposing to or directly producing cutaneous 
disease may be classified into: 

Hygienic conditions, general and personal, and the 
Constitutional conditions, family and personal, to which the indi- 
vidual may be subjected. 

GENERAL HYGIENIC CONDITIONS. 

The general hygienic conditions are climate, soil, abode, and 
seasons. 

Climate. — It is very difficult to show the exact influence of 
climate, and few are only a matter of temperature, as with it so 
many other conditions are changed, such as race, habits, soil, 
diet, etc. 

Yaws, leprosy, one form of elephantiasis arabum, phagedena 
tropica, Delhi boil and its congeners, are mainly tropical; verru- 

50 



ETIOLOGY. 



51 



gas is a disease of Peru; pinta, of Central America; tinea imbri- 
cata, of Oceana; pellagra, mainly of Northern Italy. 

Eczema is nearly always aggravated by sea air, and exposure 
to northeast winds will often determine an attack in a predis- 
posed person; and indeed, even without exposure the patient 
can often recognize by his sensations a deleterious change of 
wind. 

Soil. — With the exception of that due to malaria, and even 
that is only indirectly due to soil, little is known with regard to 
the influence of soil on skin disease; urticaria, herpes febrilis, 
and melanotic pigmentation are not infrequent in connection 
with ague, especially in severe forms. Less common are roseola, 
— a large macular erythema, either on the limbs only, or general, 
and sometimes hemorrhagic, — petechias, and other forms of pur- 
pura; while boils, carbuncles, and noma are occasionally met 
with.* 

The Abode may be insanitary and close, and conduce to 
strumous affections ; pemphigus neonatorum generally, and boils 
often, occur where the air is contaminated with sewer gas or 
other foul emanations, and in any case nutrition and vital re- 
sistance are lowered, and the occurrence of skin and other dis- 
eases favored. 

Seasons. — These exercise considerable influence; thus, in the 
spring, erythema multiforme is particularly liable to occur or 
recur; while, on the supervention of warmer weather, hydroa 
aestivale and urticaria papulosa, which had been quiescent in the 
cold weather, begin to recrudesce; psoriasis also often becomes 
active in the spring. Prurigo varies; some cases being worse 
in summer, some in winter. Prickly heat is only a disease of 
very hot weather. In autumn erythema multiforme is only a 
little less common than in spring. In winter many diseases are 
aggravated, notably lupus, ichthyosis, eczema, and many other 
inflammatory diseases; while chilblains, pruritus hiemalis, and 

* Brocq records a case of papulo-vesicular eruption on the nose of a lady 
which waxed and waned at periods corresponding with a double tertian 
ague. After resisting all his efforts for weeks it disappeared in a few 
days with quinine. The patient had never had distinct ague, but lived 
in a malarial country for several months in each year, and Brocq thinks, 
with Verneuil and Merklen, that there is a group of skin eruptions worthy 
of being called " Paludides." — Brocq, Annates de Derm., vol. viii., 1896, 
p. 1. 



53 DISEASES OF THE SKIN. 

Raynaud's disease are especially diseases of cold weather.* 
There is, moreover, a summer pruritus, which is less common 
than the winter form. There is also a set of f recurrent erup- 
tions of variable clinical characters some of which recur in sum- 
mer and some in winter, while occasionally they overlap. 

Sudden alternations of heat and cold, and extremes of either, 
are fruitful exciting causes of a large number of eruptions, pro- 
ducing them either dc novo or by recrudescence. 

Personal hygiene includes many causes of disease, such as: 

Occupation, which often plays an important part, chiefly in the 
production of what are called professional dermatoses; thus 
there is the large class of trade eczemas, such as baker's, gro- 
cer's, bricklayer's, barmaid's, and washerwoman's " itch," due 
either to handling powders or to always having the hands wet. 
Workers in chemical or dye factories, or with arsenic or bichro- 
mate of potash, are liable to dermititis in various forms, from 
the iritating influence of the materials in use. Callosities from 
hard manual labor are well known. Various sweat eruptions are 
seen in those exposed to heat and moisture, as in pianoforte- 
makers. 

Clolliing may be unsuitable, either in make or material, c. g., 
badly made boots produce corns or blisters; tight bands produce 
chafing or excoriations; dyed stockings often excite papular and 
eczematous eruptions; flannel excites pruritus in some skins, 
and if worn too long without washing favors the development of 
tinea versicolor and seborrhea corporis. 

Unclcanlincss is a favoring rather than an exciting cause of 
cutaneous disease, especially for parasites, both vegetable and 
animal. On the other hand the constant stimulation of the skin 
by the too frequent use of soap, especially if not carefully made, 
is liable to excite eczematous eruptions. Washing without great 
care in drying is a frequent cause of chapping, and vapor baths 
may excite malaria. Where eczema exists it is nearly always 
aggravated by water, unless it is quite soft like rain or distilled 
water. 

* " Cold as an Etiological Factor," Corlett, Amer. Jour. Cut. Dzs., vol. 
xii., 1894, November No., and Monatsh., vol. xxiii., 1896, p. 531. 

f " Winter and Summer Recurring Eruptions," by the author, Brit. 
Jour. Derm., vol. xii., 1900, p. 39. 



ETIOLOGY. 53 

Food, improper in quality or quantity, is an important factor in 
the production of a large number of diseases. It may do this, if 
inadequate in quantity or quality, by lowering nutrition gener- 
ally, or by its directly irritating effects on the gastro-intestinal 
mucous membranes. Or it may be of a quality which promotes 
fermentation in the alimentary substances in the stomach. As 
examples may be given the use of starchy food in young infants, 
which often remains undigested, and acts injuriously, both by 
lowering nutrition and acting as an irritant, especially when 
there is intestinal catarrh; the effect of taking food containing 
branny particles, such as brown bread, oatmeal, etc., on eczema- 
tous and urticarial patients; and the influence of beer, pastry, 
etc., in exciting fermentation. More direct is the gastric irrita- 
tion produced by shell-fish, especially mussels, which excite vio- 
lent urticaria in some people. Then again certain diseases are 
ascribed to food, as pellagra to the consumption of decomposed 
maize, leprosy to decomposed fish, but the latter theory is not 
generally accepted. 

Medicines. — Many drugs produce erythematous and urticarial 
eruptions when taken internally, which are referred to in detail 
in the section on drug eruptions; and a few, like iodin and bro- 
min, produce eruptions of a special character. 

Irritants. — Many drugs, plants, and other substances, when 
brought into contact with the skin, excite inflammation in it. 
Cantharides, turpentine, mustard, croton oil, rhus toxicoden- 
dron, and arnica may be cited as examples. Vide Dermatitis 
venenata. 

Scratching is only another form of external irritation; the 
lesions it produces have already been detailed under Excoria- 
tions. It is, however, only where the itching is very severe, as 
in that produced by scabies, pediculosis, or prurigo, that the 
worst effects of scratching are produced. In senile pruritus, for 
instance, the skin is rarely injured to any material extent. 

Contagion is responsible for not a few skin diseases; animal 
and vegetable parasitic diseases, impetigo contagiosa, the exan- 
themata, early syphilids, glanders, and malignant pustule, are 
some of the contagious or inoculable diseases. 



54 DISEASES OF THE SKIN. 

RACE AND FAMILY CONSTITUTIONAL 
CONDITIONS. 

Race. — Very little is known of the effect of race apart from 
endemic conditions, special customs, and personal habits of 
different races. Negroes are certainly more liable to yaws and 
keloid than the white races, and according to Morrison* of 
Baltimore, less liable to lupus and acne, and their skins are less 
sensitive to external irritation. The grave affection, " idiopathic 
multiple pigmented sarcoma," appears to occur chiefly among 
the Jews, and those mostly from Poland and Galicia; but this 
may be more a matter of habits and of local causes than a racial 
peculiarity. Leukoderma also is more common in colored races; 
but here again they are more exposed to the sun, and the con- 
trast makes the affection more noticeable. 

Heredity f exercises an important influence in the production 
of disease, but its influence is considered to have been formerly 
overrated. Thus the heredity of leprosy is now a disputed point. 
Some explain away its supposed heredity by assuming either 
that the disease is communicated by contagion from one mem- 
ber of the family to another, or that they are all subjected to the 
same environment, which is the real etiological factor. In other 
cases it is only a similar tissue proclivity that is transmitted, 
and if the pathogenic microbe, e. g., the tubercle bacillus, is ex- 
cluded, the supposed hereditary disease will be avoided. Even 
admittedly hereditary diseases vary much in the degree of pro- 
clivity induced thereby; in some, as syphilis, the disease, when 
in an active condition in the parent, is almost certain to be con- 
veyed to the child; in others, as psoriasis and ichthyosis, the 
transmission is uncertain. If there are several children, some 
will probably be affected while others escape; on the other hand, 
in the majority of cases of these diseases there is no evidence of 
heredity. Eczema is probably not at all hereditary; but states 
predisposing to it, such as gout, feeble digestion, etc., are so. 
No doubt, too, some skins resent irritants more readily than 
others. Some diseases are only occasionally hereditary, such as 

*" Personal Observations on Skin Diseases in the Negro." A paper 
read before the Amer. Derm. Soc. Congress, 188S. 

f " The Pedigree of Disease," by J. Hutchinson, London, 1884, may be 
consulted for a more complete account of the subject. 



ETIOLOGY. 



55 



xanthoma, premature baldness, tylosis palmse. In some in- 
stances of heredity there is a tendency to be limited to one sex 
in the family through several generations. 

Family prevalence may or may not be associated with heredity; 
and here again the family liability is often confined to one sex. 
Of this, the rare affection xeroderma pigmentosum is an exam- 
ple — e. g., in a family of eight boys and five girls, seven of the 
boys and no girls were affected, while no instance of heredity is 
known. Ichthyosis is another example in which there may or 
may not be heredity and family prevalence often limited to one 
sex. 

PERSONAL CONSTITUTIONAL CONDITIONS. 

Sex exercises a certain influence. This may be dependent 
upon anatomical peculiarities. Thus, it is obvious that sycosis 
can only occur in a male, and Paget's disease of the nipple in a 
female. On the other hand, it is not always so — c. g. } lupus 
erythematosus is much more common in women, and epithe- 
lioma is more common in men. The different habits of the two 
sexes no doubt also play a part. Thus, the minor form of acne 
rosacea is more common in women, from their greater liability 
to dyspepsia and constipation, owing to their sedentary habits, 
and partly, perhaps, to uterine derangement being another ex- 
citing cause; on the other hand, the worst forms are seen in 
men, from their more frequent intemperance and exposure to 
severe weather. The special conditions affecting women at 
different periods of life are described under the effects of age.* 

Age. — The influence of age may be considered under two 
aspects. First, as regards merely the duration of the life of the 
individual; and, secondly, as regards epochs or events which 
occur at different periods. Speaking generally, in early life 
there is a greater tendency to the more acute forms of inflam- 
mation and to overgrowth; in old age, to lower forms of inflam- 
mation and to degenerative and atrophic diseases. In infancy, 
eruptions are more likely to take a pustular form, and from the 
ease with which the alimentary canal is deranged there is a 
greater liability to eczema or urticaria. 

* Guibout, " Lecons cliniques stir les Maladies de la Peatt," 1879. PP- 
1000, divides skin diseases as they affect childhood, adult life, and old age. 



5 6 DISEASES OF THE SKIN. 

In the first three months of life congenital syphilis generally 
shows itself; at the end of the first year ichthyosis generally 
begins, though it may be earlier, and even be congenital. In the 
second year begins xeroderma pigmentosum. Psoriasis is very 
rare under three years old, and not common under five years. 
Ringworm of the head occurs in childhood only, for the most 
part, while tinea versicolor is hardly ever seen in childhood; 
on the other hand, vegetable parasitic diseases are rare after 
fifty. Acne rosacea begins to be prevalent about thirty, just 
when the tendency to acne vulgaris has ceased. Among animal 
parasitic diseases, pediculi corporis are rare in children, while 
pediculi capitis are almost universal among the children of the 
poor. Lupus vulgaris generally begins in childhood; lupus 
erythematosus rarely begins before the patient is grown up; 
impetigo contagiosa is more common in childhood, chiefly be- 
cause children are more exposed to contagion. Cancerous affec- 
tions are uncommon before middle age. 

In connection with age there are certain events in life which 
often exert an influence; among these 

Vaccination may be mentioned. Although not a natural proc- 
ess, its practice is so general as to be almost equivalent to it. 
The influence of vaccination occupies a large place in the public 
mind as an etiological factor in skin diseases, but only a very 
small one among medical men. That it is directly or indirectly 
responsible for some skin troubles cannot be doubted, and they 
are discussed under their appropriate headings; but the majority 
of cases ascribed to vaccination are only due to confusing the 
post with the propter hoc. 

Dentition is another process in early life which is much over- 
estimated as a cause of skin disease, even by the profession, by 
whom it is too often set up as a " bogy " for the ills of infancy. 
It has little if any direct influence, but there is doubtless a con- 
dition of unstable equilibrium, just before the eruption of a 
tooth, in which the child is easily upset, and during which any 
skin disease present, such as eczema or urticaria, is likely to be 
aggravated. 

Puberty. — At puberty the glandular and hairy systems take on 
increased activity, and the line between physiological and patho- 
logical activity is liable to be overstepped. Hence disorders of 
the sebaceous glands arise, such as seborrhea, comedones, acne 



ETIOLOGY. 57 

vulgaris, bromidrosis, and hirsuties in girls are met with; at this 
time, too, many date their first onset of psoriasis and lupus, 
though both may begin earlier. Some diseases, such as ichthyo- 
sis and eczema, dating from early childhood, sometimes undergo 
amelioration. 

The next four relate to women only. 

Menstruation only produces eruptions when it lowers nutrition 
by the excess of discharge; but many eruptions, such as urti- 
caria, acne vulgaris or rosacea, and eczema, are aggravated a 
few days before the menstrual flow occurs; while a few, such as 
herpes labialis, an erysipelas-like eruption of the face, erythema 
circinatum on the back of the hands, fugacious erythema else- 
where, and purpura, have been observed to recur at each period, 
without anything abnormal in the menses being present. In 
the absence of the catamenia, hematidrosis has been observed, 
being possibly a vicarious phenomenon.* 

Pregnancy. — In connection with this state may be noticed the 
so-called herpes gestationis (see Dermatitis herpetiformis), and 
the fatal impetigo herpetiformis. Urticaria is not uncommon, 
and pruritus without any rash is often most troublesome, either 
general, or at the vulva only. Eczema is less frequent, chloasma 
is very common, and herpes febrilis is rather common. On the 
other hand, eczema or psoriasis may clear up during pregnancy, 
while most of the eruptions which occur during pregnancy clear 
up soon after parturition. 

Lactation often exercises an influence, doubtless by lowering 
nutrition; thus women liable to psoriasis are very likely to have 
a fresh outbreak at that time, or an old attack aggravated. 
This is also true of eczema and other diseases dependent on low- 
ered nutrition. 

Climacteric. — At this time many diseases crop up or are aggra- 
vated, among which acne rosacea, seborrhea capitis with conse- 
quent baldness, and the ubiquitous eczema, may be specially 
mentioned. 

Constitutional predisposition occurs apart from either heredity 

* See also Danlos, " These de Paris," 1S74; Deligny, Le Concours Medi- 
cal, April 14, 1888; a good abstract in Amer. Jour. Cut. and Gen.-Ur. 
Dzs., vol. vi. (1888), p. 315; Brit. Med. Jour., March 3, 1870, quoting 
Schramm and W. Wagner; Grellety, translated in Wood's " Medical and 
Surgical Monographs." 



5 8 DISEASES OF THE SKIN. 

or family prevalence, although often associated with those fac- 
tors, and exercises more frequently an indirect rather than a 
direct influence. This may be seen in the liability of many per- 
sons to eczema on exposure to irritating influences, either ex- 
ternal or internal, which would not affect the majority of people. 
Probably this is analogous to the liability many people show to 
catarrh of the mucous membranes, which is often to a great ex- 
tent restricted to different regions in different people, c. g., in 
and on the nasal mucous membranes, the pharynx, larynx, bron- 
chi, or even stomach or intestines. How much is congenital, 
and how much acquired, is difficult to say in many cases; but I 
am a strong believer in the skin itself acquiring a bad habit, so 
to speak, and reacting to deleterious influences varying in dif- 
ferent people, probably through the vaso-motor nerves. 
Chronic urticaria and allied conditions are examples of this, and 
manv striking instances of the sensitiveness increasing bv the 
repetition of the exciting cause are related amongst the drug 
and irritant eruptions. 

It is certainly the case with many patients as regards eczema, 
especially when they have just got over an attack, and probably 
the liability to recurrence of erythema multiforme, hydroa, and 
of psoriasis, and to a less extent lichen planus, may be similarly 
explained. With regard to some of these diseases another pos- 
sible explanation is that pathogenic microbes have periods of 
quiescence and activity, the latter stirred up sometimes, perhaps, 
by external influences. 

Certainly the chance of permanent cure largely depends on 
the patient being able to avoid the exciting causes of the several 
diseases, for a considerable period. I am, however, no believer 
in the so-called herpetism of Bazin, or the dartrous diathesis, of 
Hardy, except in the above very limited sense. Bazin's arthritic 
diathesis is so far true that gout and rheumatism have an un- 
doubted predisposing influence in some diseases, e. g., eczema, 
though I believe even this has been pushed too far by his school; 
and that many cases, c. g., of scleroderma, pityriasis rubra, etc., 
are associated with rheumatism, because they own a predisposi- 
tion to a common cause, viz., chill, and not because they stand in 
the relation of direct cause and effect. The greater liability of 
certain persons to parasitic diseases, which is admitted bv most 
authors, is explicable in another way. The predisposition to 



ETIOLOGY. 59 

vegetable parasitic diseases lies probably in some anatomical 
peculiarity of the skin or hair follicles, or, as in tinea versicolor, 
in a greater tendency to perspire; while, with regard to animal 
parasites, probably some peculiar odor of the individual exer- 
cises an attraction on the insect. 

Another point is that the same cause will, in one person, ex- 
cite one kind of eruption, while in another a totally different 
form will be produced, though the same disease will generally be 
seen in the same individual under similar influences. 

Internal Diseases. — In all cases of cutaneous disease defects in 
health, whether dependent upon disease in one part or in the 
whole of the organism, require careful investigation. Any low- 
ering of the general vitality, either from defects in assimilation, 
defective nutrition — often the result of the first — or defective 
nerve power often shown in increased irritability, is an impor- 
tant predisposing factor of cutaneous as well as of other 
diseases. 

The digestion should always claim our first attention. The 
diseases most directly connected with disturbance of the ali- 
mentary canal are urticaria, acne rosacea, and eczema; pruritus, 
both general and local, and all inflammatory diseases are liable 
to be aggravated by it. The effects of irritants from food and 
medicine have already been considered. 

It is often difficult to separate functional disorder of the liver 
from that of the alimentary canal, as they are generally asso- 
ciated together more or less. The disease of the skin most di- 
rectly associated with that of the liver is xanthoma, which in its 
generalized form, in an adult, is almost invariably associated 
with chronic jaundice. Severe pruritus is common, pruritus ani 
and urticaria being generally due to it, and urticaria is not infre- 
quent in jaundice, or even in derangements much less severe 
than this. 

Diseases of the Kidney. — Albuminuria is not a productive cause 
of skin disease; in my experience pruritus, urticaria, dermatitis 
herpetiformis, and as a consequence of scratching, ecthyma, and 
eczema in a few instances, are most directly associated, chiefly 
with the granular contracted kidney in the earlier stages, in 
which the general lowering of vitality also has a part, as well 
as the albuminuria. Defective kidney elimination is a probable 



60 DISEASES OF THE SKIN. 

predisposing cause of senile eczema, even when there is no al- 
buminuria, while the vulnerability of the senile degenerated skin 
to microbic invasion is another factor to be borne in mind. 

In the more advanced stage of Bright's disease, especially of 
the granular form,* purpura, and, more important, a diffuse ery- 
thema, are not rarely observed. Huet of Holland first drew at- 
tention to uremic erythema, recording twenty-seven cases. Af- 
ter him, Bruzelius of Denmark, many French observers, Pye- 
Smith, Le Cronier Lancaster, and Thursfield have written 
about it. 

The most characteristic eruption occurs in fingernail-sized 
erythematous discs, but it may be morbilliform, scarlatiniform, 
or patchy at first, but in any case it speedily becomes a diffuse 
red, superficial dermatitis, often universal, and generally fol- 
lowed by desquamation of the whole body surface in large 
flakes, leaving the skin thickened and red; or eczema may de- 
velop and vesicles, bullae f or pustules may be produced. As a 
uremic phenomenon it is of grave significance, unless the uremia 
can be successfully combated for a time. In one of my cases 
this was accomplished, although uremic convulsions had oc- 
curred, and the patient made apparently a good recovery, and 
went about with only slight albuminuria. Subsequently she de- 
veloped a diffuse and very extensive but not universal lupus 
erythematosus of the head, face, and trunk, but she lived for five 
months after the uremic erythema. Other cases of lupus ery- 
thematosus with albuminuria are on record. 

For further details see Thiebierge's and Thursfield's paper on 
the whole subject. f 

Bullous eruptions in connection with uremia have been re- 

* Colcott Fox reported a case in an old woman with granular kidneys 
in whom hemorrhagic erythema developed seven days before death, and 
went on to a universal severe purpura with melena and retinal hemor- 
rhages. 

f A. Barrs, Brit. [our. Derm., January, 1896, p. 9, relates the case of a 
uremic bullous eruption. 

% " Des Relations des Dermatoses avec les Affections des Reins et 
1' Albuminuric," G. Thibierge, Annates de Derm, et Syph , vol. vi. (1885), 
pp. 424, 511. He gives extensive references up to date. Since then 
Chartier's "These de Paris," 1S89, Lancaster in Clin. Soc. Trans., 1892, 
and Thursfield's paper in the Medico-Chirurg. Trans., vol. lxxxiii. (1900), 
and the discussion, p. 235, and full biography, may be especially men- 
tioned. 



ETIOLOGY. 6 1 

corded by Murchison, Duckworth, Barrs, and Persy. The last 
is the most conclusive of the relationship of the two diseases, as 
a bullous eruption on the lower limbs occurred on two occasions 
along with uremic convulsions and coma. Pityriasis rubra has 
also been observed in a few cases towards the end of Bright's 
disease (chiefly granular kidney), but there are many more in 
which Bright's disease has developed towards the end of pity- 
riasis rubra. 

Toxins in the blood acting on the vaso-motor centers is the 
most probable pathogenic theory of all these rashes. 

In diabetes, Kaposi,* in a paper on this subject, found xerosis, 
pruritus, urticaria, acne cachecticorum, roseola and erythema, 
eczema (especially of the genitalia), balanitis and balanopos- 
thitis, and vulvitis, boils and carbuncles, gangrene, perforating 
ulcer of the foot, and to these must be added the rare xanthoma 
diabeticorum, the so-called diabetic bronzing, although the 
diabetes is often a late symptom. 

Other Urinary Constituents. — Of excess or deficiency of other 
urinary constituents no general statement of etiological value 
can be made.f Bulkley's paper, founded on 2000 pretty com- 
plete urinary analyses from 569 patients in his private practice, 
is chiefly remarkable for its negative aspects. 

Only 26 patients showed albuminuria, 15 glycosuria. The 
most recent changes were, in their order of frequency, an excess 
of amorphous phosphates, oxalate of lime, uric acid, urates, 
triple phosphates. The variations in the quantity of urea, both 
in excess and deficiency, were less than might be anticipated, 
taking two per cent, as the normal average. In discussing the 
urine in eczema, psoriasis, acne, pruritus, etc., the same discrep- 
ancies were present, and no general deduction could be drawn 
beyond showing that " there are errors of nutrition and metab- 
olism in many patients with skin diseases." 

On the other hand, skin diseases may lead to disease of the 
kidneys; thus chronic universal dermatitis in any form is, liable 
to lead to albuminuria just before the fatal termination; and 

* IVz'ejier medici7iische Presse, No. 23, December, 1883. Abs. in An- 
nates de Derm, et Syph., vol. v. (1884), p. 28. 

f " Imperfect or Deficient Urinary Excretion as observed in connection 
-with certain Diseases of the Skin," by L. D. Bulkley. Reprint from 
Avier. Derm. Trans., i8qq. 



6 2 DISEASES OF THE SKIN. 

Augagneur cites many cases continuing the opinion that sup- 
purative dermatitis may induce nephritis. Temporary glyco- 
suria is sometimes seen in association with eczema, but here 
they probably only own a common cause. 

Diseases of the Respiratory System. — Although these can 
scarcely be considered causes of skin disease, spasmodic asthma 
is sufficiently often associated with cutaneous disease to show 
that there is a relation between them, but probably only that of 
common origin. Bulkier* gives a very complete resume of our 
knowledge of this subject. Urticaria, eczema, and ichthyosis are 
the diseases associated with true spasmodic asthma in my ex- 
perience. Gaskoin also connects psoriasis with it; but this is 
not in accordance with either Bulkley's or my own experience. 
Bulkley also, in 948 cases of acne, found 7 with asthma. This 
would scarcely imply more than coincidence. The occurrence 
of herpes febrilis with croupous pneumonia is due to the onset 
of the latter disease being generally ushered in with a well- 
marked rigor. 

Diseases of the Circulation. — The most important is that slug- 
gish circulation of the blood in the extremities, and perhaps also 
in the nose and ears, sometimes called the " chilblain circula- 
tion,"! in which the hands and feet are habitually cold, of a 
more or less livid redness, and not infrequently moist also. In 
this condition Richardson has shown that, while the heart is ap- 
parently acting strongly, the tension in the radial pulse may be 
so low that it is extremely difficult to get a sphygmographic 
tracing. This is not only a strongly predisposing cause for chil- 
blains, and their occasional sequel, angiokeratoma, but also for 
lupus erythematosus, one form of which Hutchinson calls " chil- 
blain lupus." He also relates three interesting cases in women 
with feeble circulation in which there were diffuse local conges- 
tions of the face, hands, and feet, with tendency to ulceration and 
general failure of nutrition. Vide Dermatitis recurrens hie- 
malis. 

In Peripheral Ischemia the blood is unable to enter the capil- 
laries, as seen in " dead or waxy fingers," and in Raynaud's 
disease; obstruction to the general circulation, such as occurs in 

* Brit. Med. Jour., November 21, 1885. 

f An extreme instance is depicted in Plate 32 of Hutchinson's Ar- 
chives of Surgery, vol. iii., 1891. 



ETIOLOGY. 



63 



emphysema and mitral disease, may manifest itself in the skin as 
marked telangiectases on the face; while local obstruction, such as 
varicose veins, predisposes to eczema, ulcers of the lower limbs, 
pigmentation diffuse or in " orange stains," and to elephantiasis, 
though in this lymphatic obstruction must also concur. 

Chills as an exciting or aggravating cause of dermatitis of 
various kinds, at one time universally accepted, is now often 
denied, since so many skin inflammations formerly thought to 
be of nervous origin are with more probability ascribed to mi- 
cro-organisms or their toxins. Although the explanation may 
be different the fact remains, and in my belief cannot be disputed 
in many instances. It seems to me probable that in the reaction 
following a chill of a large surface of the body, the blood which 
was driven inwards will return with increased force, draining the 
viscera for the time being, and leading to the absorption of 
toxins from the intestine or other viscus, which may excite a 
more or less extensive dermatitis, which varies either with the 
difference of the toxin or the special vulnerability of the indi- 
vidual. The role of toxins and of the nervous system in the pro- 
duction of skin eruptions is set forth in the section on 
Pathology. 



PATHOLOGY. 

The pathology of diseases of the skin follows the same laws 
as those of other tissues, modified by the special differences from 
other structures in the normal anatomy of the skin. The patho- 
logical processes — anemia, congestion, inflammation, hypertro- 
phy, atrophy, and neoplastic growths — are all represented in the 
various diseases of the skin, though anemia only produces tri- 
fling functional derangements, such as pallor and coldness of the 
surface, and sometimes cold sweating. In addition, owing to its 
exposed position, parasites, both animal and vegetable, are 
much more frequent in comparison. The vegetable parasites 
which are known to produce disease belong for the most part 
to the hyphomycetes or fungus family, but there is no doubt 
that the schizomycetes, to which bacteria and micrococci belong, 
play a more important part in the production of many inflam- 
matory diseases and even apparently new growths, especially of 
the granuloma class, than has, until recently, been suspected. 
At the same time, micrococci are so ubiquitous that, although 
their invariable presence in the skin structures may be demon- 
strated in any particular disease, it is not until pure cultures 
of them have been obtained, and the disease reproduced by them, 
that it can be considered proved that they are the true morbific 
agents, although the suspicion may be very strong on other 
grounds. 

The diseases in which a schizomycetic microbe is known to be 
the cause are those due to pus cocci, those due to the seborrheic 
bacillus, to the tubercle bacillus, leprosy bacillus, and the rarer 
diseases, anthrax, glanders, and rhinoscleroma. There are still 
a larger number in which a microbic origin is a practically cer- 
tain inference, but the organism has not yet been isolated and 
demonstrated as the fons ct origo mali. 

Psorosperms are no longer considered to be pathogenic agents 
in the skin, the bodies mistaken for them having been proved to 
be metamorphosed epithelial cells. 

6j. 



PATHOLOGY. 65 

There can be no doubt that the bacillary products called 
Toxins, whether introduced from without the organism or ab- 
sorbed from within (auto-toxins), are important agents in the 
production of skin diseases. It is unknown whether they act di- 
rectly on the skin through the circulation, or indirectly through 
the nervous system; probably they do not always act in the 
same way. It must, moreover, be admitted that, in the great 
majority of instances, their action cannot be proved; they are 
only assumed to be the real factors with more or less proba- 
bility. 

Such are the skin eruptions which occur in the course of, 
or as the sequelae of, the exanthemata, gonorrhea, diphtheria, 
influenza, beri-beri, septicemia of all forms, acute rheumatism, 
and tuberculosis, and the antitoxin serum injections,* and those 
of tuberculin. So, too, a large proportion of the scarlatiniform, 
morbilliform, diffuse, and even the exudative multiform ery- 
themata, urticaria, many bullous eruptions, and most hemor- 
rhagic eruptions, are in all probability also of toxic origin. With 
all these the list is by no means exhausted, but it is useless to go 
further in this direction, into the realms of hypothesis. Still 
less is known of the action of leukomains and ptomains, but 
something is known, and more is suggested as to the effects 
of retention of morbid products as in jaundice, glycosuria, 
granular kidney, and the absence of the thyroid, etc. What is 
known suggests that further inquiry on all these lines will have 
fruitful results. 

The Primary Plaque. — Brocq first pointed out that in pity- 
riasis rosea there is a primary patch which exists for some days 
before the generalization of the eruptions. This idea is, I be- 
lieve, capable of extension to many other diseases of less acute 
course. I have often been able to trace a similar mode of de- 
velopment in first attacks of psoriasis and lichen planus, but it 
is not discernible in recurrences of these diseases. Probably it 
occurs in other diseases also. The inference is that the micro- 
organisms or their toxins multiply in the primary plaque, and 
then are absorbed into the circulation. 

Eosinophilia. — Leredde is a strong advocate of the importance 

* Dubreuilh's observations are in favor of the rashes which often follow 
anti-diphtheritic serum injections, being due to its being obtained from 
the horse, and suggests, therefore, that other animals should be used. 
5 



66 DISEASES OF THE SKIN. 

of these cells, when in excess in the blood, as indicative of a 
toxic action, and wishes to found a class of " hematodermites," 
to include all cases in which eosinophilia is notably present. 
Much more research is required before this view can be ac- 
cepted, but it is more fully discussed in the pathology of pem- 
phigus and dermatitis herpetiformis. 

Nervous System. — The etiological connection of the nervous 
system with cutaneous disease has been much discussed of late 
years, especially as to what are, and what are not, trophoneu- 
roses. In the present state of our knowledge this is largely 
academic, except where anatomical changes in the nervous sys- 
tem can be demonstrated. The facts relating to this part of the 
subject have been sumirfarized by myself,* and these show that: 
While the nervous system may determine the occurrence, dis- 
tribution, extent, and intensity, it has no influence on the kind of 
eruption; and, further, that less serious consequences ensue 
from cutting off the nervous supply than from irritant or in- 
flammatory lesions of the parts of the nervous system that affect 
the skin; that the kind of eruption produced by the nervous sys- 
tem varies greatly, often without any evident reason, when the 
nervous effect is apparently the same in place and kind; that 
the same eruption may owe its origin to any defective link in 
the nervous chain from the center to the periphery; that the 
same kind of nervous lesion, that at one time appears to excite 
an eruption or other nutritive defect in the skin, even more fre- 
quently, produces no change in the skin whatever. 

The lesions other than atrophic, which result when innerva- 
tion is abolished, are often traceable to external injurious in- 
fluences which the tissues, when unprotected by the nervous 
system, are unable to resist; but we know nothing of the condi- 
tions that determine the nature of the eruption or other skin de- 
fect, when the nerve lesion is irritative, nor what it is that de- 
termines whether there shall be any eruption or none at all. 

*" Lesions of the Nervous System etiologically related to Cutaneous 
Disease," Brain, vol. vii. (1884), p. 343, with many references to literature 
and cases. There is also a good summary of the position of the nervous 
system in relation to diseases of the skin by Auspitz in Ziemssen's " Hand- 
book," p. 124. Schwimmer's " Die neuropathischen Derrnatonosen," is 
an excellent monograph; Kopp, "Die Trophoneurosen der Haut," and 
Leloir's writings may also be consulted. 



PATHOLOGY. 67 

This uncertainty of effect suggests that the nervous influence is 
an indirect one. 

The cerebral effect appears to vary according to whether its 
control over the vaso-motor center is increased or decreased, 
and to the secondary changes it induces in the cord. No local- 
izing lesions have yet been found for its influence on the vaso- 
motor center. In the spinal cord the fibers that preside over the 
nutrition of the skin are bound up with the sensory fibers, and 
reside, therefore, mainly in the posterior columns. Outside the 
cord the path is by the posterior roots, the spinal ganglia, and 
the sensory fibers, and lesions of any one or more of these may 
lead to changes in the skin. 

The changes observed in Graves Disease * must be reckoned 
as indirectly nerve phenomena. In this abnormalities of pig- 
mentation have been constantly noticed, such as freckles, local 
or general bronzing, and leukoderma; a greasy condition of the 
skin, cold sweating of the palms or soles, dryness and thinning 
of the hair and nails are also frequent. Vaso-motor instability 
shows itself in urticaria, typical, factitious, or as localized edema; 
hemorrhagic erythema is occasionally seen. 

Localization. — While the skin, as a whole, is often affected al- 
most from the beginning in the different processes enumerated, 
the individual skin structures may be found, to a certain extent, 
to take a predominating part in some diseases ; but it is excep- 
tional for one alone to be affected, and the longer the process 
lasts the more likely is the whole skin to be involved. Thus the 
vegetable parasitic diseases invade chiefly the upper layers of the 
epidermis; the horny layers are greatly hypertrophied in tylosis 
and other callosities; the prickle-cell layer is chiefly involved at 
first in psoriasis; the papillary layer in eczematous inflammation; 
the deep part of the corium in sclerodermia; in acne vulgaris, 
the inflammation is chiefly about the sebaceous glands; in papu- 
lar diseases, round the hair follicles ; in miliaria, about the sweat 
apparatus. Eczema is a good example of an inflammation be- 
ginning in the papillary layer, and extending, when of sufficient 
duration, to the whole skin structure both above and below it. 

*Dore, Brit. Jour. Derm., vol. xii., 1900, p. 353, gives a good resume 
and bibliography. 



DIAGNOSIS. 

A thorough knowledge of general and special semeiology 
and pathology is essential to the formation of an accurate diag- 
nosis, the importance of which is so obvious as a necessary pre- 
liminary to successful treatment that no insistence on it would 
appear necessary, were it not that it is too often vague and in- 
definite, not only from ignorance of the characters of skin dis- 
eases, but from want of system, thoroughness, and trained ac- 
curacy of observation. 

Such feeble attempts as " erythema," " pityriasis," " lichen," 
and " lichenoid," with which so many are content, are utterly 
useless, both for designation and as a guide to treatment; and if 
those who uttered them only realized that they were merely say- 
ing redness, scaliness, and pimples in a foreign language, they 
would not take so much trouble to say so little, though no doubt 
they are convenient cloaks to conceal ignorance from the pa- 
tient. 

A certain method is necessary in conducting the investigation. 
The patient should always be placed in a good light, and it is 
essential in most cases that it should be daylight; so much is 
color, especially if at all yellow, modified by artificial light that, 
unless this is unusually white, eruptions of a faint yellow may 
be overlooked altogether. Jullien recommends a cobalt blue 
glass as an aid to the early recognition of secondary syphilids. 

Completeness of Examination. — The whole eruption should al- 
ways be seen, if possible, as a perfectly erroneous idea may be 
conveyed by merely seeing the part presented by the patient, 
which is selected either because it gives the most annoyance or 
is the most easy of access, while the most typical features of the 
rash are perhaps only to be found elsewhere. 

In men and children there is no difficulty, as they can always 
be stripped if the room be properly warmed; while in women, 
one has often to be satisfied by seeing the eruption by install- 
ments; but where there is any doubt, this at least should be in- 

68 



DIAGNOSIS. 69 

sisted on, as the patient would be the first to blame the doctor 
if any error arose from imperfect examination; at the same 
time, the subject must be led up to with gentleness and tact, 
after preliminary conversation has put her at her ease. 

On first seeing a patient, the sex, apparent age, general con- 
formation, complexion, and aspect are noted. Certain ques- 
tions are then to be asked. " How long have you had it?" is 
the first and most important; it often clears the ground of so 
much, and will, in many cases, be decisive as to the nature of the 
disease. Thus, in a widespread erythematous eruption, a dura- 
tion of two or three weeks would at once exclude all the exan- 
themata for which it might be mistaken; or, in an infiltration, a 
duration of several years, with very slow extension, would point 
to lupus rather than syphilis. 

The next question is, " What was its course? " A large num- 
ber of eruptions develop in a characteristic way, and alter con- 
siderably from their first appearance. This is especially the 
case in erythema multiforme, in many cases of eczema, in urti- 
caria papulosa, etc. An eruption is also often modified by vari- 
ous circumstances besides time, such as scratching, poulticing, 
or previous treatment by another practitioner. 

Then the eruption may come out all at once, as in herpes; or 
in successive crops, as in pemphigus; or by continuous or inter- 
mittent spreading, as in pityriasis rubra, and in many cases of 
eczema; or some lesions will be coming and others fading, as 
in secondary syphilids and hydroa; or again, there may be con- 
stant recurrences just when the disease appears to be cured, as 
occurs commonly in eczema. 

The third question is, " What symptoms, especially as regards 
itching, fever, etc., attended or preceded the eruption?" 

The fourth question, " What is its cause?" has to be an- 
swered, as a rule, by the doctor himself, after eliciting from the 
patient, by question and physical examination, the various ex- 
ternal and internal conditions antecedent to the outbreak. A 
knowledge of general and special etiology is necessary for com- 
plete investigation on this point, which would be deferred until 
the nature of the eruption has been determined. Whether the 
eruption is only part of a general disorder, or is a disease of the 
skin itself, will often be decided by the presence and nature of 
the constitutional symptoms. 



7° 



DISEASES OF THE SKIN. 



The physical characters of the eruption must now be ex- 
amined. 

The eruption as a whole should primarily engage attention, 
first as regards its distribution and extent. The importance of 
noting the distribution cannot be too much insisted upon. It is 
halfway and often more to the diagnosis, generally pointing 
in the direction in which further investigation should be 
made. 

Thus, it may be universal, as in pityriasis rubra, pemphigus 
foliaceus, or lichen acuminatus; general, in many cases of ec- 
zema and psoriasis, and many erythematous eruptions; and 
more or less limited to one region or part in a large number of 
eruptions. It may be symmetrical, as in lupus en thematosus; 
unsymmetrical, as in lupus vulgaris; unilateral, as in herpes zos- 
ter and morphea; irregular and disseminate, as in scabies and 
parasitic eruptions generally; though in tinea versicolor it is 
generally irregular and aggregate. Then, is the lesion single, 
as in rodent ulcer; or multiple, as in most eruptions? Is it of 
uniform character, as in scarlatiniform eruptions; or multiform, 
as in syphilis, scabies, and eczema? Investigating still more 
closely, is there any definite arrangement of the individual le- 
sions, either in groups in the course of a nerve, as in herpes zos- 
ter; or in circles or segments of circles, as in tinea circinata, 
etc., or in lines, as occurs sometimes in lichen planus; or in 
patches, round, oval, or irregular, as in psoriasis and many 
others? 

The lesion itself has now to be examined. Is it a primary 
lesion, such as a macula, an erythema, a papule, nodule, tumor, 
or infiltration; vesicle, bulla, pustule, or wheal; or some special 
lesion, as a wart, horn, or burrow: or is it a secondary lesion, 
and therefore scaly, scabbed, or crusted, excoriated from 
scratching, or otherwise fissured, ulcerated, scarred, or stained? 

Then, its pathological nature must be determined. Is it due 
to congestion, inflammation, hemorrhage, hypertrophy, atrophy, 
a neoplasm, or a parasite, either animal or vegetable? 

Finally, the general condition of the skin must be noted, 
whether it is dry or moist, greasy or rough, etc. 

The various points of inquiry may be grouped in the follow- 
ing way to impress them on the mind of the student, as they 
affect the patient, his disease, and the lesion. 



DIAGXOSIS. 7I 

SEX. 

Occupation PATIENT General Condition, 

AGE. 

SYMPTOMS. 

Duration DISEASE Course. 

CAUSATION. 

DISTRIBUTION. 

Nature LESION Effects. 

CHARACTER. 



TREATMENT. 

Diseases of the skin should be treated upon the same princi- 
ples as diseases of other organs, and require, therefore, an ac- 
curate diagnosis, supplemented by a correct appreciation of their 
etiology and pathology. Unless the practitioner has a sound 
knowledge of general medicine, his treatment, except in a few- 
local affections, will generally be as unsatisfactory to the pa- 
tient as it ought to be to himself, and he will be driven to resort 
to the miserable subterfuge of the bungler, that " the rash is bet- 
ter out than in." The popular idea that it is dangerous to cure 
eruptions quickly, or, as the laity put it, " to drive the rash in," 
is as erroneous as the notion that nearly all skin diseases are due 
to impurities in the blood. Their external position facilitates 
the application of topical remedies; and as the skin, like other 
organs, may be idiopathically diseased, local treatment may then 
do all that is required; so, too, it is often sufficient when, al- 
though the internal cause has ceased to act, the skin disease per- 
sists. And even when local remedies are not curative, they may 
be valuable palliatives and contribute much to the comfort of the 
patient. 

In a large proportion of cases the combination of internal 
and external treatment is nearly always advantageous, and often 
necessary, for the comparatively rapid and effectual treatment of 
the majority of skin affections — hyphomycetic and animal para- 
sitic eruptions, some atrophies and neoplasms, being the most 
notable exceptions to the value of internal treatment. Internal 
remedies are often of value even in bacterial diseases, as in many 
of them the condition of the organism plays an important part 
in favoring or otherwise the development of the microbe. Even 
in some hyphomycetic diseases, such as actino- and blasto-my- 
cosis, internal medication has proved an important aid. 

INTERNAL TREATMENT. 

The character of the internal treatment depends upon the con- 
stitution, peculiarities, and general state of health of the pa- 

72 



TREATMENT. 73 

tient, in nearly all cases. It is comparatively seldom that the 
name of the disease of the skin is the determining factor, and it 
is not until the most careful investigation has failed to detect 
any departure from health that resort should be had to one or 
other of the few drugs which act, or are supposed to act, directly 
on the skin. Since there is no organ or system which may not 
be directly or indirectly the main factor in the production of 
some skin affection, it is obvious that, from this point of view, 
an attempt to discuss the treatment of skin affections by attack- 
ing the organ primarily at fault, would be really a dissertation 
on general therapeutics; and because this is not attempted in 
this work, and attention only called to the more direct means 
at our command, it must not be supposed that it is considered of 
small importance; indeed, advancing knowledge shows that the 
more experience and medical acumen the physician possesses, 
the less is he driven to resort to arsenic and other specifics. 
General hygiene, tonics, such as iron, cod-liver oil, quinine, the 
mineral acids, nux vomica, etc., play a large and important part 
in the treatment of skin eruptions, and when they are indicated 
on general grounds, should be given regardless of the nature 
of the skin lesion in most cases; but this is not without excep- 
tion. Thus sea air aggravates the great majority of cases of 
eczema, even where such a climate would be otherwise indicated; 
while in the interval of the attacks it may be highly beneficial. 
Probably, of all conditions requiring attention, dyspepsia and 
other disorders of the alimentary canal are the most important. 
Alkalies, bismuth, vegetable bitters, nux vomica, and the various 
means for producing regular evacuation of the bowels, are con- 
stantly in requisition. 

Dietary naturally plays a most important part. This must be 
suited to the condition of the digestive organs of the patient, 
but even when these are sound, it must always be borne in mind 
that most inflammatory affections have an intimate sympathy 
with the gastric mucous membrane, and whatever irritates that 
aggravates the skin trouble. The dietary, therefore, while it 
should be as nutritious as possible in most cases, should be bland 
and easily digestible; all highly spiced food, condiments of all 
kinds, should be avoided: salted foods are also often injurious, 
because they are less digestible, and tend to give the stomach 
more trouble, though thev need not alwavs be absolutely pro- 



74 DISEASES OF THE SKIN. 

hibited; oatmeal, and bran-containing preparations generally, do 
not suit those who have acute inflammatory affections; again, 
infants and young children with gastro-intestinal catarrh, either 
acute or chronic, can seldom digest starchy food, which should 
therefore be avoided, or given sparingly, and then with 
maltine. 

Alcohol is a subject on which patients are very anxious. Speak- 
ing broadly, as a rule, the less the better, except in very moder- 
ate doses; alcohol dilates the vessels of the skin, and is there- 
fore contra-indicated in inflammatory affections, in which it 
generally aggravates the pruritus and increases the hyperemia. 
Nevertheless, in persons of weak digestion, a small quantity at 
the beginning of a meal, especially after fatigue, will often, on 
the one hand, make just the difference between eating with an 
appetite, digesting well, and consequent restoration from the 
fatigue; and on the other, aggravating the exhaustion from the 
patient having too little vital energy to eat or digest. In elderly 
people, also, it is seldom wise to break up too suddenly the 
habitual use of alcohol, or indeed almost any habits not posi- 
tively deleterious. 

Alcohol should generally be given, if at all, in the form of a 
very small quantity of a pure spirit well diluted, or one of the 
lighter wines, such as claret or hock, which must, however, be 
perfectly sound or mature. As a rule, the stronger wines, such 
as port and sherry, and the imperfectly fermented products, such 
as beer, porter, and the sparkling wines, are more or less in- 
jurious. 

Of the more direct remedies, a foremost place belongs to 

Arsenic. — Unfortunately, with too many it is used indiscrimi- 
nately, as if it were a panacea for all cutaneous woes; but this is 
far from being the case, and it is often positively injurious. To 
get good results from its use it must be employed intelligently, 
and with a definite aim as to its intended modus operandi. Ar- 
senic acts in two ways, in my belief — directly on the skin, pick- 
ing out and acting especially, if not entirely, on the diseased 
tissue, i. e., in what one may call a local manner; or it may act 
as a stimulant to the peripheral ends of the nerves, and perhaps 
to the vaso-motor and trophic centers. 

Physiological experiments made by Ringer, Murrell, and Miss 
Nunn on the frog, show that it acts powerfully upon the epithe- 



TREATMENT. 75 

lial layers. The epidermis peeled off the dermis, beginning at 
the deeper layers, the degeneration progressing from within 
outwards; and in the human subject, universal desquamation en- 
sued in a case of poisoning. That the action is mainly a local 
one is shown in the treatment of psoriasis, for while under its 
use old patches often get quite well, new ones may form, even 
when the patient is fully under the influence of the drug. Its 
local action is further illustrated by its deposition in the form of 
a brownish-black pigmentation, limited to the site of the dis- 
eased area. Possibly the greater instability of the cells of the 
diseased area may, to some extent, account for this apparent 
elective affinity of the arsenic. 

Other diseases in which it is of great service are chronic cases 
of lichen acuminatus, or lichen planus; in these, too, its action 
is probably chiefly on the epithelial layers. 

Its action through the nerves is seen best in pemphigus, der- 
matitis herpetiformis, and chronic urticaria not dependent on 
digestive derangements, and in frequently recurring erythemata, 
whether congestive, or exudative, or hemorrhagic, and in re- 
curring sweat eruptions. 

In small doses it is useful in controlling iodid and bromid 
eruptions, but its modus operandi is not clear. 

Arsenic is contra-indicated in nearly all acutely inflammatory 
affections, which are often aggravated by it, and the pruritus is 
generally much increased in affections dependent on indigestion 
or other irritable conditions of the alimentary canal, owing to 
its irritating the gastric mucous membrane, as in most cases of 
acne rosacea, dyspeptic urticaria, and active eczematous erup- 
tions; indeed, it is scarcely ever necessary or even desirable in 
eczema, although largely prescribed by many practitioners. 
Even in psoriasis, and other diseases where it is generally suita- 
ble, it should not be commenced until all derangements of 
health, other than that of the skin, have been rectified as far as 
possible. Arsenic is seldom of any benefit in deep-seated in- 
flammations, or in non-inflammatory affections, but Kobner has 
found good results in hypodermic injections for multiple sar- 
comata. 

The mode of administration is of importance. It should al- 
ways be given after food. Although there are a large number 
of preparations, the most important are the liquor arsenicalis, 



7 6 DISEASES OF THE SKIN. 

or Fowler's solution, arsenious acid, and the new salt cacodylate 
of soda. 

The other preparations, such as the liquor sodse arseniatis, 
liquor arsenici hydrochloricus, solutions and syrups of bromid 
of arsenic, arseniate of iron, etc., have their advocates, but prac- 
tically all the good that can be obtained from arsenic can be 
obtained with one of the first three preparations, though Dono- 
van's solution occasionally finds a place, when it appears desira- 
ble to administer arsenic and mercury simultaneously. When 
Fowler's solution is given, it should be always well diluted and 
combined with a vegetable bitter, tinctura lupuli being one of 
the best, and if there is any gastric discomfort a little tinctura 
opii is a useful addition. Some begin with a small dose, and 
gradually increase it up to ten, or even twenty minims, if the pa- 
tient bears it well; others commence boldly at once with ten 
minims. Although in a good many cases this latter plan suc- 
ceeds, if it should irritate, it may render it impossible to give 
the drug at all, for some time to come. The more cautious 
method is therefore safer and preferable. Arsenious acid is 
given in the form of a pill, and the portability of pills often ren- 
ders the solid form more convenient for the patient. The Asi- 
atic pill (see Formulae at the end) is a favorite method on the 
Continent. A formula much used by myself is, arsenious acid 
gr. i, pulv. glycerrhizse gr. xxix, ext. lupuli 3 i; divide in pil. 30. 
One to be taken three times a day after meals. 

Some authors, notably Hunt, think that arsenic should be 
pushed until its toxic effects are produced; this is, in my opinion, 
always to be avoided, if possible. Puffy eyelids and irritation 
of the conjunctiva should always be a sign to diminish the dose, 
though not necessarily to suspend it altogether. In some peo- 
ple very moderate doses will produce severe gastro-intertinal 
irritation and necessitate the abandonment of the treatment. 
It must be borne in mind that fatty degeneration of the liver 
and kidney, with albuminuria, may be induced by the prolonged 
administration of full doses ; and in the skin, general pigmenta- 
tion and keratosis of the palms and soles, which in a few in- 
stances has led to cancer. 

Cacodylate of Soda. — Cacodylic (Dimethyl-Arsenic) acid is an 
organic compound of arsenic (As (CH.) 2 O. OH). Although 
the sodium salt contains forty-six per cent, of arsenic, it is 



TREATMENT. 77 

claimed that the equivalent of large doses of arsenic may be 
given without toxic effects on the organism, and without irritat- 
ing effects, whether given by the stomach, rectum, or subcuta- 
neously; further, its therapeutic advantages are said to be very 
great. Danlos found it to be particularly efficacious in psoriasis, 
general lichen planus, dermatitis herpetiformis, and tubercular 
glands, and in all general diseases in which arsenic is indicated, 
especially pernicious anemia and phthisis. The sodium salt is 
free from the virulence and offensive smell of the acid, it is 
highly deliquescent, and therefore cannot be given in ordinary 
pills. The dose recommended is four-fifths of a grain per day 
to begin with, which is equivalent to nearly forty-eight minims 
of Fowler's solution, and increased up to I 1-2 grains or ninety- 
five drops of Fowler's solution. On the other hand, when given 
by the mouth it becomes rapidly changed in the stomach and 
produces an intense alliaceous odor of the breath and urine. 
Moreover, its alleged non-toxic effects are only relative. 
Murrell found that after eleven one-grain doses of the sodium 
salt in pill sudden and dangerous symptoms of acute arsenical 
poisoning were produced. It is obvious that it is not safe to be- 
gin with anything like the dose recommended above; probably 
one-twelfth of a grain would be quite enough. Personally, I 
should be inclined to risk such a dangerous drug only in serious 
diseases, like general sarcoma, and then give it hypodermically, 
for which a formula is given in the Appendix. It can also be 
obtained for this purpose in sterilized tubes which contain one 
cubic centimeter of aseptic solution containing five centi- 
grams, or .8 grain, which is the French daily dose, to be given 
for a week, and then rest a week. 

Salicin and Salicylates. — In 1895 I published a paper* upon 
the advantages of salicylate of soda in psoriasis and some other 
diseases of the skin. A very large experience enables me to 
speak with more confidence of its value; but salicin has been 
substituted for salicylates, as the latter have so often disagree- 
able effects, while salicin rarely disagrees. Briefly stated, it 
covers the same ground as arsenic, often succeeds where the lat- 
ter fails, e. g., in a spreading psoriasis, and is likely to be success- 
ful in all diseases in which the presence of a pathogenic microbe 

* Lancet, June 8, 1895, p. 1421, and Brit. Jon?'. Derm., vol. vii., 1S95, 
p. 229. 



78 DISEASES OF THE SKIN. 

is probable. It is particularly successful in extensive cases of 
psoriasis, of lichen planus, in pityriasis rosea, and in bullous 
affections, in many hyperemic forms of lupus erythematosus, 
and has proved of temporary benefit in several cases of mycosis 
fungoides, some infiltrations disappearing, and even some tu- 
mors diminishing, and in one case of multiple giant-celled sar- 
coma large numbers of the tumors involuted in a few weeks. 
To obtain such results the dose must be an adequate one, not 
less than fifteen grains three times a day after meals, and this 
dose may be increased to twenty or twenty-five grains; larger 
doses are rarely required, but experimentally sixty grains three 
times a day have been reached without ill effects. Sometimes it 
has disagreed with the digestive organs, in a few cases it has 
produced headache and depression, and very rarely a scarlatini- 
form rash. It has been of no service in eczema except for its 
hepatic action, and is contra-indicated in most cases of pityriasis 
rubra. 

Thyroid Gland. — Besides its well-known effect in removing 
the symptoms of myxedema, as long as it is taken, it has also 
been strongly recommended in other diseases of the skin, chiefly 
through the advocacy of Byrom Bramwell, especially for 
psoriasis, ichthyosis, and lupus vulgaris. Its value in some 
cases of these diseases is indisputable, although, unfortunately, 
it has not fulfilled all that, at first, one was led to hope. Its 
value is greatest in lupus vulgaris, and its indications and limita- 
tions are laid down under the treatment of the several diseases 
mentioned. The most convenient method of giving it is five 
grains of the dried gland in tabloid form. It is important to be- 
gin with a single tabloid a day, and increase it by weekly in- 
crements until fifteen grains a day is reached, reducing the 
dose if " thyroidism " is produced. Much larger doses have 
been given when the patient has been kept in bed, but it is 
rarely desirable, and if the patient is going about, unsafe. It is 
best given after meals. Thyrocol is the active colloid matter 
from the gland, and is said to be more regular and reliable thsn 
the gland, and there are no products of decomposition in it. It 
is five times stronger than the gland, and its initial dose, there- 
fore, is one grain. Other derivatives have been suggested. 

Quinine. — Besides its administration as an ordinary tonic, it 
is also sometimes useful in a more direct way; thus, in the acute 



TREATMENT. 79 

stage of pityriasis rubra, in dermatitis herpetiformis, where ar- 
senic fails, or for other reasons, and in the febrile exacerbations 
of leprosy, quinine is often most serviceable. It is generally 
necessary to give large doses; five grains every four hours will 
sometimes be required; given in an effervescing form, with 
potash or soda, the alkaloid being dissolved in the acid mixture; 
if the bowels are kept open it rarely disagrees. In chronic 
urticaria, in furunculosis, and dermato-neuroses generally, and 
wherever there is a malarial taint, quinine finds an important 
place in smaller doses. 

Antimony. — The employment of this drug in small doses finds 
strong advocates in Jonathan Hutchinson and Malcolm Morris ;* 
the latter used it in doses of rr>iij to nyvij of the wine in acute 
and subacute general eczema of adults and children (in appro- 
priate doses), in some hyperemic cases of psoriasis, and in pru- 
rigo. To a certain extent I can bear him out, but the cases 
must be very carefully selected, and where there is any debility 
or gastric irritation it should be avoided, as I have seen a 
limited eczema spread widely under its administration. Mr. 
Hutchinson gives it to a very much greater extent in senile and 
other eczemas, often with opium.t 

Antipyrin. — This drug has the recommendation of Blaschko, 
partly indorsed by Kobner, for the relief of symptomatic itching 
in prurigo, eczema, lichen planus, and senile pruritus, and as 
actually curative in some cases of pemphigus and of urticaria, 
especially that of children. It is certainly a valuable adjuvant 
in urticaria, and in some cases of dermatitis herpetiformis. It 
will also often relieve the pain of zoster. 

Phosphorus has had advocates in the treatment of psoriasis, 
eczema, and lupus erythematosus. It may be given in the form 
of phosphorated oil, in capsules, or in coated pills. A limited 
experience has not enabled me to say much in its favor. 

Turpentine was introduced by myself for inflammatory erup- 
tions, and it is certainly useful in uncomolicated cases of eczema 
and hyperemic cases of psoriasis, and other forms of dermatitis 
in which hyperemia is the most prominent symptom. It checks 
some purpuras, and in a few cases of cancer it has also appeared 
to exercise a retarding effect. The method of administration, 

* Brit. Med. Jour., September 22, T883, p. 572. 

f Jamieson also speaks favorably of ii.—Edz'n. Med. Jour., June, 1892. 



80 DISEASES OF THE SKIN. 

which must be strictly observed, is described in the Appendix 
(Miscellaneous Mixtures). 

Tar and Carbolic Acid have been given for psoriasis and ec- 
zema, the first in capsules, the latter in pills, gr. 2 in each dose. 
Both Kaposi and Liveing speak in praise of carbolic acid for 
psoriasis. 

Sulphur has a much higher reputation among the laity than 
among the profession. It is, however, highly to be recom- 
mended, in my experience, in hyperidrosis and sweat eruptions 
generally; and sulphid of calcium, as Ringer showed, is one of 
the best drugs for furunculosis, and is useful in the freely sup- 
purating forms of acne. Calcium sulphid to be of any use must 
be freshly made, and inclosed in properly coated pills, or it 
soon becomes inert. 

IcJithyol is a distillation product of a peculiar bitumen from 
Tyrol, with sulphuric acid. As met with in pharmacy, it is 
really ammonium sulpho-ichthyolate, and is a treacle-like liquid 
with a disagreeable odor, miscible with water and fats. The 
soda salt is also in use. It contains a considerable proportion 
of sulphur, some of which is eliminated by the skin, of which I 
received an unwelcome proof in the case of a lady who, after 
taking ichthyol for some time for an erythematous eruption of 
the face, used a lactate of lead lotion, and almost immediately 
the sebaceous secretion of each pore was turned black, giving 
the appearance of the skin being thickly covered with small 
comedones. To Unna belongs the credit of introducing it, and 
he and many of his followers claim a very high place for it in so 
large a number of diseases of the skin, including leprosy, as 
should considerably simplify cutaneous therapeutics. As an in- 
ternal remedy, I have found it useful in reducing some of the 
hyperemia in affections of the face, such as in some of the 
erythemata, lupus erythematosus, and acne rosacea. It appears 
to do this by leading to the contraction of dilated vessels, and 
sometimes it may do so indirectly by its beneficial effect on ca- 
tarrh of mucous membranes. Thus, while giving it to a lady 
with lupus erythematosus of the face, she was entirely cured of a 
severe dysmenorrhea of twenty years' duration; conditions due 
to chronic rheumatism are also benefited by it. The dose is 
three to five minims in pills or capsules. As a local application 
it occupies only a small place in my practice; it is too dirty and 



TREATMENT. 81 

disagreeably smelling an application to allow of its being used 
except at night, without the patient giving up his avocation. 
It has, however, many friends, who recommend it for numerous 
and diverse complaints; I have found it most useful in some of 
the seborrheic forms of dermatitis. 

It is least objectionable combined with a zinc gelatin paste, 
and this is the form in which I generally employ it for dry ec- 
zemas; but lotions, soaps, varnishes, and ointments are used. 
Unna classes it with pyrogallol and chrysarobin as a reducing 
agent. 

Thiol (made by heating oil gas with sulphur) is very like 
ichthyol in its action and appearance, but without its disagree- 
able smell; it may be obtained either as a forty per cent, liquid or 
as a powder. Whether internally it acts like ichthyol I am not 
yet sure, but I have found it useful in some cases of recurrent 
winter eruptions, as an external application combined with Las- 
sar's or zinc gelatin paste in subacute eczema without much 
discharge, and have also used it as a one or two per cent, lotion. 
Schwimmer claims good results with it, used externally, in ery- 
thema multiforme. 

Tummol (bitumen and oleum) is another candidate for favor 
in this class. Neisser speaks well of it for moist eczema of 
moderate severity, superficial burns, and ulcers. It is really 
tumenol sulphonic acid, and is a dark powder with a slightly un- 
pleasant odor. 

Resorcin is also recommended by Unna for a similar class of 
cases. This, with sulphur, ichthyol, sugar, linseed oil, and other 
reducing agents, when diluted, and applied locally, act as kerato- 
plasty agents, as Unna calls them, i. c, they " make the swollen 
and defective horny layer harder, thicker, and drier, so that it 
may again become more fit to take up fat." Resorcin is a good 
antiseptic and parasiticide, and being soluble in water and spirit, 
and neither objectionable in color or smell, is useful in many 
affections, such as eczema when dry, lupus, ringworm, favus, 
seborrhea, epidermic thickenings, etc. 

Iodin and Iodids. — Besides their use in syphilis, especially in 
the tertiary stage, iodin and its preparations are of great utility 
in strumous affections. Liveing is a strong advocate for the use 
of the tincture in three to five minim doses, for lupus vulgaris, 
and in small doses the potash salt is often very useful in gouty 
6 



82 DISEASES OF THE SKIN. 

eczema; much smaller doses are required for non-syphilitic affec- 
tions than for the syphilo-dermata, except in the case of 
psoriasis, for which gigantic doses have been recommended by 
Haslund. 

Diuretics. — Just as the skin can often be made to help the 
kidneys in their difficulties, so can the kidneys be called in to 
the aid of the skin. Many chronic inflammations, and some 
acute ones, may be relieved by diuretics, the acetate and other 
preparations of potash being the chief aids in cases with a gouty 
or rheumatic taint, or wherever there is defective elimination the 
spirit of juniper and the infusion of broom may often be use- 
fully combined with these salts. They should all be given 
freely diluted, and the neutral salts given after meals. 

Aperients. — In all cases the bowels should be kept free, and 
in acute inflammatory diseases, especially eczema, it is often 
desirable to begin with saline aperients; the sulphates of 
sodium and magnesium, in equal parts, form an almost tasteless 
combination. Rochelle salt, in the form of seidlitz powder, is 
another useful form, and the stock combination of carbonate 
and sulphate of magnesia with a carminative is constantly in 
requisition. The sulphate of magnesia in combination with sul- 
phate of iron (Startin's mixture) for acne vulgaris is extremely 
valuable. In pruritus ani the importance of easy action of the 
bowels is obvious, but, in all cases, regularity without effort, 
rather than intermittent violent purgation, should be aimed at. 

'Mineral Waters. — These have held a high place in skin affec- 
tions from time immemorial. The various springs useful in skin 
affections are discussed at the end of this work; only those taken 
away from their source are alluded to here; they are chiefly the 
alkaline and aperient waters. Vichy and Carlsbad, the latter 
laxative also, are the chief alkaline waters; while the aperient, 
many of which are also more or less alkaline, are numerous; 
Friedrichshall, Piillna, zEsculap, Hunyadi Janos, Radocsky, 
" Victoria," Offner, Apenta, and Rubinat are the most useful, 
their relative strength being in the order in which they are 
enumerated. A heaped teaspoonful of Carlsbad Sprudel salt, 
dissolved in two-thirds of a tumberful of warm water, and taken 
before breakfast, is most useful; it is alkaline, and acts generally 
once or twice freely, not more. Sulphur waters, such as Harro- 
gate and Strathpeffer, are of value where there is a rheumatic 



TREATMENT. 83 

taint. Levico is ferruginous and is the strongest arsenical water 
known. Roncegno is another ferruginous arsenical water. La 
Bourboule and Royat contain arsenic, but in much smaller 
quantities. 

Intestinal Disinfectants. — The doctrine of auto-intoxication by 
absorption from the intestine has suggested the use of intestinal 
disinfectants, or those which prevent gastro-intestinal fermen- 
tation, and a good deal of success has attended their use in some 
cases of eczema and urticaria. Creasote, spirit of chloroform, 
and sulpho-carbolate of soda are most used when action in the 
stomach is desired, while in the intestine, those which are only 
soluble in the presence of alkalinity are preferable. Salol, 
benzo-naphthol, naphthol /3, subnitrate of bismuth in large 
doses, when the bowels are relaxed; they certainly correct or 
prevent offensive motions and flatus. 

Counter-irritation over the vaso-nwtor centers has been used by 
me with great success in obstinately recurring eczema, and simi- 
lar inflammatory attacks. A mustard leaf, or blister, is applied 
over the vaso-motor center controlling the region affected, viz., 
behind the ears for the face, along the cervical spine (cervical 
enlargement) for the bust and arms, over the three lower dorsal 
and first lumbar spines (lumbar enlargement) for the genital or 
genito-anal region and lower limbs, or just behind the trochan- 
ter for one limb only. It always relieves the pruritus for some 
time, and often leads to the subsidence of the inflammation, or, 
if used when an exacerbation of an active eczema is threatened, 
will often abort or considerably mitigate the aggravation. 



LOCAL TREATMENT. 

No part of the body is so exposed to parasites as the skin, 
even in its normal condition, and any disturbance of the surface, 
especially of an inflammatory character, opens wide the door 
for their entrance. It is therefore scarcely to be wondered at 
that as the knowledge of the noxious influence of many of these 
organisms increased, so also did efforts to destroy them, or 
prevent their entrance. The consequence has been the employ- 
ment of microbe destroyers on the one hand, and of various 
methods of coating the skin to exclude the air, on the other. 



84 DISEASES OF THE SKIN. 

In a word, the keynote of modern dermo-therapeutics is Anti- 
sefticism. 

Fortunately, the skin offers greater facilities for the applica- 
tion of local remedies than any other organ. They are em- 
ployed either to cleanse, give temporary relief, or as curative 
agents. 

Baths stand first as cleansing agents, to remove scales, crusts, 
offensive and other secretions; when plain water is used, boiled 
or rain water is best; for scales or crusts alkaline baths are 
most useful, as in psoriasis and ichthyosis. In eczema and 
very active hyperemic states baths are generally injurious, so 
that they must not be used indiscriminately, and in eczema, 
therefore, soaking the part with olive oil or boric acid starch- 
poultices are the best means to remove any scales or crusts., 
Medicated baths are used, both as palliative and curative agents. 
As palliative may be mentioned baths of alkalies and mucilag- 
inous substances, such as starch, bran, size, marshmallow, etc., 
for urticaria and parasitic itching, and in many inflammatory 
conditions. As curatives may be instanced baths of sulphur in 
scabies, of tar in some obstinate forms of eczema and psoriasis, 
and the continuous bath in some severe forms of pemphigus and 
burns. 

Soaps are also used medicinally and as cleansing agents; soda 
or hard soaps are used for ordinary cleansing, but soft or green 
potash soap is most efficacious in removing scales, and is much 
used in ringworm, psoriasis, and seborrhea. 

As curative agents may be mentioned Hebra's soft-soap 
treatment for chronic eczematous infiltration, and, combined 
with spirit and oil of cade, for psoriasis of the scalp and knee. 
Without the oil of cade it is also useful for comedones. Many 
drugs have been added to a soda-soap foundation, c. g., carbolic, 
salicylic, and boric acids, thymol, naphthol, sulphur, etc., but, as 
a rule, medicated soaps are of small curative value, as they are 
so largely diluted and usually applied so transitorily, while in 
few diseases can soaps be applied continuously, as they are 
then slightly caustic; further, many antiseptics, such as per- 
chlorid of mercury, undergo decomposition with the soap- 
basis, and as antiseptics are inert. 



TREATMENT. 



35 



" Manilla " is a very excellent liquid potash soap, with a large 
percentage of glycerin. It is useful in comedones and for 
cleansing purposes, but has not enough fat for use on the face. 
For toilet purposes it is important that there should be no ex- 
cess of alkali, and the best transparent and other soaps are 
neutral. Unna goes further, and advocates an over-fatty soap, 
i. e.j one containing four per cent, more fat than is necessary for 
the neutralization of the alkali; and Kirsten's " Mollin " is a soft 
soap, containing seventeen per cent, excess of fat (suet and 
cocoanut oil), and with the potash, a little soda and three per 
cent, of glycerin. 

Poultices of bread or linseed are favorite applications, both 
as soothing remedies and in acute inflammations, as in boils, 
and to remove scales and crusts; but they are apt to do more 
harm than good, by acting as culture media for germs, and only 
those of an antiseptic character, such as boric acid starch poul- 
tices, wet boric acid lint, carbolized wet Gamgee tissue, etc., 
should be used where heat and moisture are indicated. 

Bandages are highly useful in supporting relaxed tissues 
and in keeping on other dressings, as in all inflammatory erup- 
tions below the knee, especially where there are varicose veins. 
Martin's india-rubber bandage is very useful in ulcers of the 
leg and in elephantiasis arabum, and the crepe bandages are 
light, porous, and elastic. 

Ointments are probably the most universally applicable reme- 
dies for skin diseases. They consist of various fats, in which 
medicaments are intimately mixed or dissolved. The fats most 
commonly employed are — lard, preferably benzoated, which re- 
tards decomposition; petroleum fats, such as vaselin, white 
vaselin, etc.; and lastly, lanolin, introduced by Liebreich, a 
cholesterin fat obtained from sheep's wool. Compound fats are 
also employed occasionally, such as spermaceti, or white wax, 
or paraffin wax, and olive or almond oil in various proportions, 
according to the consistence required. Resorbin is another 
compound put forward as possessing great penetrating power. 
It is an emulsion of almond oil and white wax with a little 
water, gelatin, soap, and lanolin. Of all these benzoated lard 



86 DISEASES OF THE SKIN. 

is the most universally employed. The vaselins at one time 
threatened to supersede it; but it was found that the claim that 
they did not turn rancid was not sustainable, and that then they 
were very irritating, and even fresh vaselin irritates a few 
skins, possibly from some want of care in the manufacture; 
finally, Shoemaker and others assert that its penetrating power 
through the tissues is very inferior to that of lard or lanolin. 
Lanolin has great penetrating power, and is especially useful 
where this quality is required, as in ringworm, for mercurial 
inunction, psoriasis, etc. It has also the advantage of being 
readily miscible with watery solutions; it is, however, very 
sticky when used by itself, and requires to be mixed with a third 
part almond oil or the heavy paraffin oil, to make a good oint- 
ment base. Ointments are of five classes — soothing, astrin- 
gent, antiseptic, stimulating, and parasiticide. The last are only 
part of a large class of remedies. 

Soothing ointments are such as protect the inflamed part 
from the injurious influences of air and moisture, and comprise 
all simple ointments, such as spermaceti, cucumber, cold cream, 
unguentum simplex P. B., etc. 

Astringent ointments are generally soothing as well as 
astringent, and comprise most of the preparations of lead, zinc, 
bismuth, boric acid, the acetate and oleate of lead (diachylon). 
The oxid and oleate of zinc and lead, and boric acid are those 
chiefly employed, and are suitable for most forms of dermatitis, 
especially eczema. To get the best effects from them, they must 
be continuously applied by being spread thickly on strips of 
linen or lint, and bound on. Unna's salve-muslin preparations 
are convenient; a loosely woven muslin is soaked in the oint- 
ment, and can be quickly and closely applied. 

Antiseptic ointments are chiefly used in pustular forms of der- 
matitis, such as pustular eczema and impetigo contagiosa, and 
comprise ointments of iodoform, iodol, boric acid, ammonio- 
chlorid of mercury, salicylic acid, carbolic acid, ichthyol, thiol, 
etc. Where there is active inflammation, weak ointments, con- 
tinuously applied, answer best. 

Stimulating and antiseptic ointments are numerous, and often 
synonymous, and only a few can be mentioned. They are of 
great utility in numerous chronic inflammations, such as 
psoriasis, chronic eczema, lichen planus, prurigo, etc. They 



TREATMENT. 87 

comprise preparations of tar and its derivatives, oil of cade, oil 
of birch, carbolic acid, etc.; thymol, naphthol, Goa powder and 
its active principle chrysarobin, pyrogallic acid, salicylic acid, 
and various preparations of mercury and sulphur. The quan- 
tity varies according to the amount of stimulation required, 
and each has its peculiarities; and much experience is required 
in the selection of the right drug and the strength of the prepa- 
ration; but where there is any doubt the weaker preparation 
should always be chosen, and at first used over a small area, 
and, if suitable, the strength increased as required. As a rule 
they are applied intermittently, being rubbed on two or three 
times a day. 

Oils and Liniments. — Simple oils, such as olive, almond, 
linseed, cod-liver, or castor oil, are bland applications, and are 
used either to soften and remove scales or crusts, or to soothe 
and protect a highly inflamed skin; thus, pityriasis rubra, acute 
psoriasis, and the like, are much benefited by being wrapped up 
in oiled bandages. The crusts of pustular eczema on the scalp, 
for instance, are best removed by strips of flannel dipped in 
olive oil and applied closely for some hours. Olive oil with 
lime-water forms the well-known Carron oil, useful for burns 
and superficial inflammations; the addition of calamin and 
oxid of zinc to this constitutes calamin liniment, which is a 
highly valuable preparation, best applied by dipping bandages 
into it and wrapping the affected part up; it is much more con- 
venient and economical than ointments when the diseased area 
is extensive, as in pityriasis rubra. Petroleum oil, as used for 
lamps, is a cheap and efficient application for extensive pediculi 
capitis. Chaulmoogra oil is used for strumous affections and 
leprosy, both internally and externally. There are also many 
essential and stimulating oils, which are used in combination 
with less active vehicles, such as oil of cade, oil of birch, oil of 
turpentine, Gurjun oil (used in leprosy), and many others. 

Lotions are applicable to a great number of forms of disease, 
and are, as a rule, more convenient than greasy applications, as 
most of them can be applied intermittently. Like ointments, 
they are soothing, astringent, stimulating, antipruritic, etc. 

Soothing lotions are a large and important class — lead ace- 



88 DISEASES OF THE SKIN. 

tate and lactate, oxid of zinc, calamin, bismuth in suspension, 
black wash, boric acid, bicarbonate of soda, and borax, are the 
most important members of this class. They are generally 
combined with a small proportion of glycerin, to prevent too 
much desiccation. Glycerin of lead subacetate, which is used 
diluted, is a most important preparation. Boroglycerid is an- 
other useful glycerin preparation, and glycerin of carbolic acid 
is a good parasiticide. They are chiefly used in active inflam- 
mations. 

Stimulating and antiseptic lotions contain corrosive sublimate, 
carbolic acid, tar (especially as liquor carbonis detergens), 
thymol, sulphur, sulphid of calcium, acids, alkalies, cantharides, 
nitrate of silver, and many others, often with more or less 
alcohol to increase the solubility or to promote evaporation and 
produce cooling. They are used in chronic inflammations, such 
as psoriasis, seborrhea, eczema, acne vulgaris, and rosacea. 

Astringent lotions have a less frequent employment except in 
hemorrhage and hyperidrosis, and contain substances like tan- 
nic acid, alum, acetic acid, etc. 

Antipruritic lotions are extremely valuable for urticaria and 
pruritus without eruption. The best are liquor carbonis deter- 
gens, sanitas, terebene, salicylic acid, carbolic acid, benzoic acid, 
hydrocyanic acid, and alkaline lotions. 

Dusting powders are used to dry up and astringe, as in 
hyperidrosis, intertrigo, and eczema. Rice, starch, arrowroot, 
kaolin, emol keleet, lycopodium, asbestos, brown or white 
filler's earth, iris root, talc, and silicic acid are the usual 
v::.icles, and with them are combined oxid and oleate of zinc, 
boric acid, calomel, oil of cade, or creasote. They must be inti- 
mately mixed, and the powder free from grittiness and impal- 
pable. Unna's plan is a good one, viz., filling long, narrow, 
muslin bags with one of these powders, quilting the bags across 
to prevent shifting, and fastening them to such parts as the 
groins, round the scrotum, under the breasts of fat women, etc., 
in eczema, intertrigo, etc. They are not suitable where the dis- 
charge is inflammatory and very copious, as they form crusts 
with the exudation, which often produce great discomfort. 

Parasiticides are animal or vegetable destroyers. Sulphur 
and its sodium, potassium and calcium compounds, destroy 



TREATMENT. 89 

both animal and vegetable life; naphthol, styrax, and Peruvian 
balsam are useful in scabies; stavesacre, white and red precipi- 
tate, and corrosive sublimate are used largely for pediculi; 
chrysarobin is one of the most powerful vegetable parasiticides. 
But their number is legion, and the reader is referred to the sec- 
tion on Parasitic Diseases for more particulars. 

Bactericides. — Iodoform stands first in importance for skin 
diseases, on account of its destructive influence on pus cocci 
and tubercle bacilli, seldom producing local irritation, as per- 
chlorid of mercury does. Iodoform, if absorbed in large quan- 
tities, is poisonous; unfortunately, too, its penetrating and nau- 
seating odor limits its use, and persistent efforts to find odor- 
less substitutes have only been partially successful as yet. 
Iodol and aristol are much less powerful; of the two, iodol is 
rather stronger than aristol in my experience, and is a fair sub- 
stitute for iodoform where that cannot be used. Dermatol has 
not fulfilled its promise; it is a bismuth subgallate, it is much 
weaker than iodoform, and is of no use for chancres. I have 
used europhen with more satisfaction; it is an iodin compound, 
with an odor compared to saffron, but not very strong. It can 
be used in the same cases as iodoform, except, perhaps, where 
tubercle bacilli are concerned, and acts well, though it is prob- 
ably not quite so powerful a bactericide as iodoform. Loretin, 
another iodin compound, is of distinct value, and the odor is 
not very objectionable. Orthoform, useful as a local anesthetic, 
may, however, lead to irritation and necrosis. 

The sozo-iodol salts of soda, potash, zinc, and mercury are 
also good antiseptics; but the soda and potash salts are too 
painful to be dusted on a wound. They are, however, soluble 
in water, the sodium salt especially ; and as they are very clean, 
inodorous applications may be used in antiseptic lotions for 
hair washes, etc. Sozo-iodolate of mercury is strongly recom- 
mended by Schwimmer for the treatment of syphilis by intra- 
muscular injections, as it is much less painful than the per- 
chlorid. I also use it in the same way for leprosy. Pyoktanin, 
blue and yellow, are anilin dyes, and this circumstance rules 
them out of court for most skin diseases. They have been suc- 
cessfully employed for epithelioma and similar malignant 
growths. 



9 o DISEASES OF THE SKIN. 

Caustics are chiefly employed for lupus and new growths 
generally, and are of all grades, from discutients, such as sali- 
cylic acid, iodin, mustard, and cantharides, up to those produc- 
ing gangrene, such as caustic potash, arsenic, chlorid of zinc, 
caustic lime, nitrate of silver, ethylate of sodium, chromic and 
pyrogallic acids; the last three are not so strong as the others. 
Caustic potash is very powerful and the pain does not last long, 
but as it is liable to diffuse into the tissues farther than was in- 
tended, it must be very cautiously used. Arsenic is very valu- 
able, as it picks out the diseased tissue, but should only be used 
over a small surface at a time, as fatal absorption has occurred 
when employed over a large area. Chromic and salicylic acids 
are used for warts and corns; salicylic acid is an important 
keratolytic, in the form of plaster or paste, to remove thick- 
ened epidermis. Chlorid of zinc does good service, but acts 
slowly, and is painful for a long time, but it is more manageable 
than caustic potash. The solid stick of nitrate of silver is 
valuable for boring out lupus nodules. Acid nitrate of mer- 
cury and nitric acid are good superficial caustics, and are used 
for chancres, post-mortem warts, and lupus vulgaris and erythe- 
matosus. Other agents are in occasional use. 

Special Media. — Hard pastes. — Pick of Prague first employed 
gelatin, with a little glycerin, as a medium for applying chrys- 
arobin, pyrogallic acid, etc., without staining the clothes. 
Salicylic acid and other medicaments were also used. 

Unna has improved on Pick's formula by using less gelatin 
and incorporating glycerin, and so formed an excellent hard 
base to which may be added such medicaments as are required. 
Such hard pastes are suitable for dry eczema and other inflam- 
mations where there is little or no discharge. The paste is 
melted by placing the vessel containing it in hot water, and is 
then painted on with a stiff brush, and dabbed with cotton wool 
to prevent the surface from being sticky. He has also devised 
lead, starch, and gum pastes, but they have only a limited appli- 
cation, as they must be freshly made, and are not very 
manageable. 

Soft pastes. — One of the most useful, with something of the 
character of an ointment, is Lassar's starch, zinc, and vaselin 
paste, with a little salicylic acid, for eczema where it is dry or 



TREATMENT. gl 

when the discharge is only moderate. It is spread thickly on 
the diseased surface, and covered with a many-tailed bandage 
of butter cloth. The formulae for these and other pastes are 
given in the Appendix. 

Unna's plaster muslins are also much used. The plaster 
muslins consist of a very thin sheet of gutta-percha backed with 
undressed muslin, and coated on the right side with an adhesive 
substance, with oleate of alumina, containing one or more 
medicaments. The drug, being in a magma on the surface, acts 
more powerfully than when incorporated in the plaster sub- 
stance, in the usual way. Another variety is called Paraplasts, 
which fit and adhere well on uneven surfaces. 

The salicylic acid plasters are the most valuable with or 
without creasote, the latter being used for lupus. The others 
Unna uses most are those of mercury and carbolic acid for 
boils and other phlegmonous inflammations, resorcin for severe 
acne vulgaris and rosacea, and the zinc oxid and mercury 
plaster as a substitute for inunction in syphilis. They are pre- 
pared of different strengths, and are obtainable in this country. 

Varnishes. — A variety of these have been devised. Trau- 
maticin, devised by Auspitz, is very valuable. It consists of 
gutta-percha dissolved in chloroform ; it is troublesome to make 
properly (vide Appendix), and the British Pharmacopeia there- 
fore uses bisulphid of carbon instead of chloroform as a sol- 
vent. The varnish resulting is of good consistence, but impos- 
sible to use on account of its fecal odor. For psoriasis, for 
which traumaticin is chiefly used, five or ten per cent, of chrys- 
arobin or pyrogallic acid is mixed in and the emulsion painted 
on. Or Besnier's modification may be used — ten per cent, of 
chrysarobin in chloroform is painted on, and then varnished 
over with traumaticin. 

Collodion applications are extremely valuable, especially the 
non-flexile, which acts by mechanically compressing the part as 
well as excluding the air. Simple collodion is useful in chil- 
blains and in lupus erythematosus; for the latter, also, salicylic 
acid or resorcin is sometimes usefully added, and a two per 
cent, salicylic acid collodion I regard as most valuable for ring- 
worm. Iodin and collodion is also good. 

Other films are Kristaline, a proprietary article primarily in- 



9 2 DISEASES OF THE SKIN. 

tended as a lacquer, but recommended as an improved collo- 
dion by Leslie Phillips. It is a solution of pyroxylin in wood 
naphtha containing amyl acetate. SchifFs Filmogen, a solution 
of pyroxylin in acetone, is a similar varnish. The addition of 
castor oil and Canada balsam make these preparations flexile. 

Other varieties are made with tragacanth, such as Pick's 
linimentum exsiccans, Elliot's bassorin varnish, Unna and 
Beiersdorf's borax or glycerin casein, all soluble in water. 
There are others, soluble in spirit, such as castor oil and shellac, 
Canada balsam and collodion, etc., which have been tried with 
success in certain cases. There is scope for any amount of in- 
genuity in these pastes, but the principal aim is the same in all — 
the exclusion of the air in the most efficient and convenient 
manner from the inflamed part. 

Oleatcs. — Metallic oxids and alkaloids dissolved in oleic acid 
were first used by J. Marshall, the oleates of mercury and 
morphia being those he first employed. Subsequently he in- 
vented the zinc oleate, which I was the first to use for skin dis- 
eases. Since then Shoemaker has been a prominent advocate 
for various oleates which he had made by double decomposi- 
tion — a distinct improvement. The most valuable are — oleate 
of zinc, oleate of lead (Hebra's diachylon ointment), oleate of 
bismuth, all efficacious in eczematous inflammations; and 
oleate of mercury and oleate of copper as vegetable parasiticides. 

Mechanical means. — Instruments. — The instruments which 
are especially used in dermatology are the steel spoon and the 
curette, for scraping lupus vulgaris; the multiple scarifier and 
puncturer of Squire, Veiel, Pick, etc., for lupus erythematosus; 
various implements with a central hole, for facilitating the removal 
of comedones; needle holders; and the epilation forceps. Keyes 
has devised a cutaneous punch for removing small portions of 
skin; and Nevins Hyde what he calls a massering ball, useful 
for a species of massage in acne vulgaris. Many other instru- 
ments are from time to time advocated by their inventors, but 
have not come into general use. Most of these instruments 
are figured in the sections on the diseases in which they are 
most employed. As aids to diagnosis are various lenses, espe- 
cially a watchmaker's lens, which leaves the hands free, and 
where it has to be worn a long time may be mounted in a spec- 



TREATMENT. 93 

tacle frame. A four-inch unmounted lens, such as oculists use, 
serves the double purpose of slight magnification, and also to 
examine doubtful lupus or other lesions by glass pressure, the 
phaneroscopy of Liebreich, and the diascopy of Unna, who dis- 
pute as to priority in enunciating the idea, which is simply to 
press out the blood, which obliterates an inflammatory nodule, 
but leaves a lupous one still visible as a yellowish-brown spot. 

Cobalt blue glass, according to Jullien, enables a secondary 
syphilid to be recognized earlier than could be done by the 
naked eye. 

Electricity. — Every year almost seems to bring the discovery 
of some new means of using this agent in the service of der- 
matology. 

The Galvano-C auter y was strongly advocated by Besnier as 
very useful for lupus in all forms, but is chiefly employed now 
for lupus affecting mucous membranes, and for removing many 
small growths. 

Paquelins Cautery is also used for similar purposes. 

Electrolysis is an important agent in the permanent removal 
of superfluous hairs, in the obliteration of small dilated ves- 
sels, and in the destruction of nevi and some new growths. The 
galvanic current has been occasionally used to relieve the pain 
of herpes zoster, and for pruritus, but it and the Faradic cur- 
rent have found but small employment hitherto in dermatology, 
except in Raynaud's disease, in which galvanism has been of 
some service. 

The Rout gen, or X-Rays. — Largely through the advocacy of 
Freund and Scruff these rays have rendered important thera- 
peutic services to dermatology in the treatment of lupus vul- 
garis, in a more limited degree of lupus erythematosus, in the 
shrinkage of hypertrophic scars, in the healing of rodent ulcers 
and some epitheliomata; in coccogenic sycosis, in acne, in epi- 
lating for tinea tonsurans and favus, and the removal of super- 
fluous hairs from women's faces, though much has still to be 
learned to insure permanency of effect and freedom from risk 
of burns. Much care and experience is required to get the 
good effects without the bad, as serious sloughing with ulcers 
which take months or years to heal may ensue from too long 
or too frequent exposures or the use of " soft tubes," etc., and 
from other imperfectly known causes. 



94 DISEASES OF THE SKIN. 

The Finscn Rays. — Finsen of Copenhagen was the first to 
show the value of actinic light, from which the heat rays were 
separated, in the treatment of skin diseases. He used both 
sunlight and the electric arc with an elaborate and expensive 
apparatus, which placed it beyond the reach of most private 
individuals. 

Lortet and Genoud of Lyons, whilst utilizing the idea, devised 
a lamp of moderate bulk and price which could be used by any- 
one whose house is connected with an electric main, and this 
has superseded the original Finsen apparatus. The essential 
parts are two carbons approximated by hand-screws to form 
an arc light, a metallic double-walled shield, with a constant 
water current through it to keep it cool and guard the patient 
against the excessive light and heat. In the center of the 
shield is an aperture which can be closed by a small metallic box 
also with a water circulation; closing each end is a rock crystal 
lens to cut off the heat rays. Against the outer lens, whose 
size and shape can be adapted to the diseased surface, the latter 
is pressed firmly, as it is essential to press the blood out of the 
part to be acted upon in order to get the full effect. 

This limits its use to a small area at a time, to dry lesions, 
exuding surfaces being unsuitable, while mucous membranes 
are inaccessible; but for these the Rontgen rays are available. 
Sequeira and others have made slight modifications in the Lor- 
tet-Genoud model. The Finsen rays are used mainly for lupus 
vulgaris, for some cases of lupus erythematosus, and it is said 
that some cases of alopecia areata have been benefited by it, but 
probably only cases which could have been more easily treated 
by other means. 

The advantages are the painlessness of the treatment and the 
neat smooth scar. The disadvantages are the large number of 
exposures required, and consequent expense, unless the area of 
disease is small. 

High tension and frequency currents were first introduced into 
therapeutics by D'Arsonval, but Oudin was the first to use 
them for diseases of the skin. Some deductions must be made 
from Oudin's enthusiastic recommendations, which not only 
comprehend similar diseases to those benefited by Rontgen 
rays, but these currents are said to be especially useful in gen- 
eral and local itching, even the most violent, as in some cases 



TREATMENT. 95 

of pruritus ani, or chronic patches of eczema and psoriasis, and 
in warts. They are said to be more useful for lupus erythema- 
tosus than for lupus vulgaris. Much more experience is re- 
quired before their uses and limitations are known. 

It is suggested that all these forms of electricity, including 
static electricity, act in the same way, dimunition of blood- 
supply to the exposed area playing a chief part. 

Massage (in the vernacular, " rubbing ") is of service in as- 
sisting in the absorption of inflammatory induration, in sclero- 
derma, in sluggish circulation of the skin (e. g., " chilblain cir- 
culation "), and in acne indurata. Nevins Hyde's massering 
ball is an ingenious contrivance for carrying out the rubbing 
in awkward corners, a ball, rotating in a socket with handle, 
being the essential feature. 

Massage has been quacked as usual, having been put forward 
as a preventive of wrinkles of the face, and forms an important 
part in the armamentarium of the advertising complexionist. 

Other physical agents proposed, but not extensively used, are 
radiant heat, freezing, and exposing the part to a constant im- 
mersion in oxygen, for which G. Stoker has devised various 
forms of apparatus. Ulcers, lupus vulgaris, rodent ulcer, and 
epithelioma, etc., have been treated with some success by these 
means. 



CLASSIFICATION. 

The object of classification is twofold — to show the patho- 
logical relationship of diseases to each other, as a guide to 
community of origin; and to serve as a mcmoria tcchnica, which 
enables the multiform aspects of disease to be remembered and 
methodically studied as an aid to diagnosis. 

The first classification of any real value was that of Willan, 
though Plenck had foreshadowed it some years before. It was 
founded almost entirely on the clinical aspect of diseases, 
grouped according to their elementary lesions. Notwithstand- 
ing many other attempts, it practically held possession until 
that of Hebra was published, the main feature of which was 
that it applied the general principles of pathology to skin dis- 
eases. It is largely a classification of pathological results inde- 
pendently of their cause (on an anatomical basis), and is a great 
advance on all previous attempts. 

There are nine classes: I, disorders of secretion; 2, hyper- 
emias; 3, exudations; 4, hemorrhages; 5, hypertrophies; 6, 
atrophies; 7, new growths; 8, neuroses; 9, parasites. 

The great advantages of this system are that it is simple and 
that it deals with the accomplished facts which we see before 
us when a case comes for diagnosis, and that, consciously or 
unconsciously, we endeavor to locate the disease in one or 
other of these categories before we enter on the consideration 
of its etiology and pathogeny. It is therefore eminently suited 
for the student; for, although admittedly imperfect, and not 
quite logically consistent in all its details, while it affords no in- 
dication how the pathological changes are produced, except as 
regards parasites, it is the one which is the most practical, and, 
on the whole, as pathologically sound as our present knowledge 
permits. 

Therefore Hebra's classification, modified to suit advances in 
knowledge and clinical convenience, is still the basis of the one 
employed in this work for the primary divisions, but in the 
subdivisions the pathological and etiological relationships are 

96 



CLASSIFICATION. 



97 



pointed out in tabular and other forms as far as is possible in my 
opinion. 

In grouping together the diseases of the appendages of the 
skin, I have been influenced solely by the clinical convenience 
of studying, as a whole, all the diseases of the hair, nails, etc., 
instead of picking them out from the different pathological 
groups of inflammation, hypertrophy, etc. 

The varieties of dermatitis from drugs, poisoned wounds, etc., 
and parasitic diseases, have an etiological rather than a patho- 
logical relationship. 

There are, moreover, a few anomalous diseases, like ainhum, 
molluscum contagiosum, etc., which do not fit well in any of 
the classes; their present arrangement is therefore provisional. 
In short, feeling the hopelessness, at present, of a really scien- 
tific and consistent classification, my guiding principle has been 
what I conceive to be the most convenient, from a clinical point 
of view, without going so far as those writers who, in despair, 
have adopted an alphabetical arrangement. 

To those whose studies are more advanced, the systems de- 
vised by Auspitz in the first place, followed by Bronson and 
Jadassohn, are worthy of study. Auspitz was the first to en- 
deavor to show the pathogenesis of skin diseases. Jadassohn's 
classification, the latest of its class, is chiefly etiological, and 
the rest is physio-pathological; but, though indicative of the 
line in which advance can be made, our knowledge is too in- 
complete for it to be of great practical utility at present.* 

* Vide " La Pratique Dermatologique," vol. i., article " Classification," 
which gives a review of the principal classifications proposed. 



9 8 



DISEASES OF THE SKIN. 



a 

O 

u 

ft 



o a> 



tfi 0) 



S X! 03 

3 *-; <L> 

72 Cl rn 

*-. tfl <1> 

^ o 

o +» 

O $h 



1/1 £ 

|S 

> 03 

a 
. a> 

« s 

I a 

o3 o 
- o3 



tn On 

o3 X 

> m 





p 




cu 


a, 


a 


c 


bfl 


a; 

a 


ft 


S 
o • 


■d 

Pi 

03 


» 03 




2 S 





be • 

l> 

ft <L> 

•a a 

5 »- 

s £ 



<D 


O 






03 
S 


03 
> 


T) 


P 


<D 


bfl 


03 


Sh 





O 


Wl 





o3 
"3 

o a> 
5 ^ 

o3 3 

P5 
.Is p 

*d "So 

2 ° 

2 ?'g 
° S-2 

03 <+-i 

>o 



•g > 

s O 



U_| VM 

O 

2 b o 

« "3 I'S 



03 - 






O 

•> »h C Vh .03^ 

1^ 6.S S > 

PPh Oh ft 



.9 «j 

• • bo § 

c/i r^ bo 
a> «j © c 

2 .5 ^ ?j 



5 I 

a 03 
« o J) 



U ° x\ 



P o3 



»5§ 

a p 









ft- 
.§' 

"55 

o3 



o3 

bJD 00 
pi p 



^ 



pi ' 

a.! 

a 
pi 
> 

"03 ■ 

pj 

03 

a 

xi 



0) $-1 

ft w 



o3 
S-i 

bfl 

ft 



R 
>, 
id 
o 



0) 03 
ft ft 



r^ 2 *- A 

3 p o> S 

ft ° 'o .2 

03 •- "- ^ 
ft 



CLi 



5 a 



a. 03 

v id 
P^S 

p 2 1 2 

ft S CO 



O o3 

™B 

ci tsa 
u o 
ft W 



a 



CLASSIFICATION. g9 



s § a o * 












!■ rt -. r 1 

5fl 



K 



>> 



° © > X ;3 O ^ 13 33 

^ * S « « > > t: .a . a 5 _o m 

<: <u P P O i-i .— 3 3^ *" 






•d l<s s!°1 -§^-9 is £ g , » * 



2 , » N g 

<! 



a bo 



a 2 



Ph 



^ 75 • • a 

fa « © 

z .2 «» 



3 

X • • . • W 



2.§ : « 3 • « 8 © • .g • m £ ■ a • 

< ^ p , -°fo ,H >g< W p 

I II Ij •■'iiH-il! fi hJ 

W eft... s-. o ~ >. . .. . o 5 S «» c -3 ,£ 3 .p 



ni 






St o» b0 ~ ^ ft - - P. ft - 



>m Ah so w o £ Q £ a! § 3 



i ■ ■ g 1 S 



be P 



P 



bo 



.^^••a^- drf tJ «3 



-££§ .y^^g.J2 £ p< £ ? 2 So-2 3 -§ 

pS) 3StS^P,lgo 5 Pa -3 -a^Sg&S 

« f § 5 5 a I ft 8 § S .g -g r § | g 

ph s g *s ^ g 4 - = ^ au § ft © fe -g = - = - 8 & 

g <U ^C3P^ ft © ^ J? S w •- •" © P 



IOO 



DISEASES OF THE SKIN. 



O cj p tfi 

5h "■£ ° '"^ 

0) CD *•£ '£ 

>» P £ P - *2 JG 

(D •!-! -f- 1 r^> CD i* 

|8 .= S 31 I 

SS 3 9 £ 8 § & 

p< w :£ £ C "^ g s 

fl fl CO p >> o > 

^ to p — ' O JH 'd 

bfl 0) °T3 "a? ^ P a 

is S g,.s-a So- s<* .a 

C^ C O 4 s/i J u •£ Q-. c J^ 

^ cd . 'J3 o •- -p 7> *° « "" 13 

s -a 5 ? -a '^ § o s ft g, s . -s 

m g -^ b 5 g <-> >-. r3 ^ P -^ *p 

g g>§ g^ p* c 8~S-g- 3* g. B 

fe o--o "Co rJ1 ^. ^ ^ ^-v o ^ 

e5 

Pn 

ffi 

I 

s * ^ 

^ *a « « ,53 

h " ^ - - - ° ^ 

* « 5s oJ ^ 

Ph Co CD y 

& a a ioS£ 2 

rcj - - - *d * .p <d £ '.G ;: :: •£ - - o 



Xfl 

O w 



. C3 



O U CJ W 



« cfi ^ 

. c m cs 

^ « bO ?0^ 

US *a >^2 

Is .23 

J- y: 
<u o 
- Jrf ■*-> - - 



S 

£ a 

O G 

c3 o 
G 



S.S 8 



O O 0) 

Si 



■r-> U J-l . 

b/: a) <u a> 

p ^ ^ rrt 



G 'En 

8 .5 

P G 



^ 2 





V3 

o 




8 1 

s a 




<u 




S^ « 




G 




rQ G 




o 




c3 o 












<D 




cj cd 




^ 




.-^ ^ 




-i-j 
C3 




Ei 


Y. 


ft 




O 


h 




G G 


t^ 


>. 




o ^ 


<< 


01 




CJ CO 


H 








Z 








w 








S 








o 
















ft 






• 1 


O 






G 


(A 






+ 






r/l 




J 




CD 


. CD 


<; 


01 


fi 


CJ 


•? 




a 




o 

< 


O 
ft 
tfl 

G 


G 


»1 

P 2 




■ iH 




it! « 


> 


+ 4 


^d 'd 




+j 






< 


G 
P, 






^ 


<• 


- 


u 


bO 







g a 

o B S 



c o o 'd <— < 
<(^coHS 



CD 

'd 

bO 2 -G O 

'■s o .a ^ 

G rG o G 

CD .p G- CD 
J CJ < J 



CLASSIFICATION. 



101 





o 

<D 












> 

u 
(0 








T3 
<D 


o 






'J2 




"3 
















72 












•d 






c 













a* 


c3 




rn 


bC 


JH 




fl 


c/5 
W 
in 






G 




£ 


"d 


£ 


g 


£ 


in 

o 




bo - 

o 
U 


0) 
CD 


U 

5 



CD 


c 

5 


qpi 


O 
PI 


< 

CO 


r^ 


















P4 


1 


















o 

en 


K 


















C/2 






















S 


Tl 
















1 






















O 


O 
















W 


!U 


CJ 
it! 
















o 
Pi 


< 


Oj 





































JS * 


r/i 


o 


Cfl 




•_"^ 




x rs 


£ 


be 


c3 




Sh 




* 5 

O «J 


0) 


c 






i-i 

a> 




cj aS 












. 


P. fc! 














S-. «H 














CU CD 














»d d 














o o 














^3 X! 












o o 












in Wl 












- 



S 

o 

CD 

bo 
c 

'd 



S-1h 


-x. 


CI) 

> 


_cd 






CD * 


> 


R 


as 




c; 






CD . 


O 


E 


CD 

S3 


CJ 


d 








TO 


OS 


fi 


P - 






< < 



Ch £ - cu 
^ v d £ 

ffi C d. < 



O 72 
£ CT3 
'rt <D 

bO^ 



O X! § 

1 1 1 

o 13 bo 

o o d 

•5= o a) 

S H U 



£ ^ 



S d 
^ ^ 'o 

"3 c3 ? 

S X u 



102 



DISEASES OF THE SKIN 



p 

o 
d 

PI 

P 
>^ 

P 
CD 

bo 

o 

£ d 

o5 fe 

fa o 



o 



P bo £ 

O "- 1 w 



p s 



o 
o 






O aj 






.52 P 03 

A a * 



O 



a 

O -P 0) rv c 
£ ^ fa C/2 fa 



J-4 




.P >» 


Cfl 


ft 


4-3 




3 o 


a 


P 


P 




cP -ji 


o 


r- 




O 0) 

05 r— 


o 

<4-4 


bo 


Cfl 




a) 'o 


a 






n 




o5 T3 


in 


4_J 


bJO 


xi 


3 * 

O G 


P 


.s 


a 


5-1 


03 


■d 





Xi 


>, o 


H 


u 


o 


rt 


*-< CD 


p 

<1> 


nd 


5-H 


4-> 


0) XI 


a 




XI 


P 


p .-a 


cd 


ri 


p 


0) 


P, 04 


xi 




fa 




Cfl fa 







52 « £ 
P .p. o 
a, p a 
05 &m 

OOP 



^ .2 <u 



i «P 

S.s 

{3 

c3 
cfl 
<u 

»d 

o 



oS 

§5 

05 q 

& £ 

°0 ^5 



g g x C 1 

o .2 <u o 

■H^ (D4J 

5- i3 P 

0> Pj - 

'p G ^ o5 

P .0 G <C 



3 3 5^ 

'd ^ s T3 
££ ^ fa 



bC 



• CD 

s 

5P 

• 'a. 

w 

05 
X £ 
£ *e3 

p 4-. 

&g 

cfl ^ 

£ % o 'u 
* o tv 55 
^ bJ3^ > 



aS 
a> 

Cfl ^ 

X ' P^ 
"£ Cfl 

I | 

.0 cfl 

5 % 

OS * > 
in ni 
a^ P3 8 

CD 



a 

a. 

is- 

« o 



0) P 



'.0 

_, M 

Oj O 

p ^ p 

^ 0H^ 

04 04-p 

(U o3 p 

<W <+4 <4_| 

O O O 



PI 


p5 


ca 


a 


<+4 


cu 


o 


p 


Cfl 


Cfl 
Cfl 


<1> 




W! 




ed 


<u 


rd 


> 



> 4^ • P3 



i o 6 



8 5 "S g £.§ 



^ in •« ^ ^ P O 

'x x x 3 5 •& o 

x< fa & S ^ W PQ 



O o " 

o <u 



Of r^ 

CD "o 
0h'o) 



ar. x 






P5 o 



05 
04 rP 
fa Q O 



0) 

0- 04 04 

fa fa 



h^ 



P oj 
fa > 



cfl 

P _, 
cfl c« oj 

bO S 



CD 

'pi B^ 
> > o 

cfl P 

3 «+4 

&>= 2 

P o 

fa C7} 



S p 

T3 CD 



05 >> 
S CD cfl 

>> P> 0H 

fa fa 0} 



Cfl 

I .a 






05 

• B 

O 



o5 o 
s- P 
0*'P 

CD ^ 

fa P4 



o5 

1 o 

O i-> 

w fa 



o5 

05 5 

P O 

o g 

>-. CD 



•— •— ' >— I 05 CD 

bJO bJD P -g cfl 

§ rt S .2 I 

04 0i 5 G ° 



CD 

Cfl 

«* ^ tf 

03 <i) CD 
CD cfl 

.2 ^ "^ 
cfl 



O 

P 
CD 
cfl 

04, 

•d 
p 

05 



« bJO ^ P: ^O 
7J P 



CD fl 

CD "oD 

cj 0h O ccS 

o fa P^ fa 



o5 

S H 

o 'o 

o o 

c3 oj 

xsi in 



■uSiuag 



•^u^uSii^H 



CLASSIFICATION. 



103 



p 

o 

'So „ 
bj - 
+j 
p 
o 
U 



5 






fa rt 



J S-. 






CS 



O « 






Is 

~ a 

O 
bJ 



o3 P 

0) Ifi 
fa£ 

03 S3 

P° P 

d 3 

<0 



P -P 



bfl 


fts 


p 


n 




u 


bJ 


bfl 


£ 


>, 


n 


!-i 




C3 



X! 

cd fi 



03 Ph 

o3 



S >H > fa O fa 



•suisi^doa^ 



pa 
o 



BJ 
S3 

O 1 

0) 



a> p 

£ 1 



^ ffi fa 



p 









en 




















1 




CJ 


d 


P 


O 







03 


cd 






<U 


BJ 


P 


CO 


s 
s 


C3 


O 


aj 

cp 


0) 




ri 


fa 







8 g 

,Q > 
03 ^ 

P. 5 
O O 

■n «P 



o 



<D 



CD P 

02 «2 



o 

.5 
o 5 3 I 
fa Id < § 






CO .— 1 



'55 

CD 
> 

oj CD 

3 *P 
Ph Ph 

o3 o3 
fa fa 



SP bJO 

o .5 

S •* 

.0 a 

« P? 

• fa § 

J +3 

1= I 

a & 

P <« j_> 

.a 2 § 

£ J* 

<U CD 

02 fa 



BJ 

w o3 

O yj 

•Pj O 



<u p 

rP 5 

o "§ 

<D 1 

CO O 

S-l 

03 ^ 



^ P 
w o 



bfl' 
p 

o3 



■s a 
■*-> p 



en rP 

(D -4-» 

fa <3 



o 



CD <u 

Ph Ph 

03 a3 

Ph Ph 



0) 



£3 





Ph n 




^ 









u 







rr 


> 


BJ 3 


W2 




0) 




< 


<U 0) 


p 




p 




n 














w 


Jh Sh 


<D 


a 

.2 


r^ 


" 


: 02 


O O 


O 

oj 
^3 


s 




Oj 


02 02 


02 


s 


u 





io4 



DISEASES OF THE SKIN. 





an 3 








3 CD 








P3 i-l 








1 i § 








^.2 tn 








. o in $ 








n 2 <-> 








a) -r- 1 >-» O 








th< 

boi 
ato 
ylo 




























ftifi fl t; 








and 
and 
flam 

sta] 












K> 


M P .5 + 




P 


<50 


O O , 




h/l 


i: 


o '-m + V2 






^ 


'■3 cu _ P 
a> s- P ;p 




o 


gj 


o O P* 






<5> 


S <W CD rO 




o 


< 
Q 
z 


Pre 
etention 
eflex coi 
eborrhei 


o 
.a 
cfl 

Cfl 


(0 

-t-> 




" — ' 


u 


Ph 


P< M GO 




r»-. 



■8 5" 



■§ 

Co rj 

SI 

$-4 ^ 

i-H 00 

O J-. 

,Q CO 

CD ,fl 

00 h-> 

>,° 

%£ 

■ 1-H -4-> 

P3 C 



m 

8 2 

O o 

2 ° 

o a) a 

> t/} Ph 



b 




. 


• 


• 


o 










OO 


o 






•d 


w 








CD . 


< 


0) 






cfl 


w 


>> 






p 




S-c 00 








n 


ci CD 






£ ' 




Tf) 




CD 


I 




:,> 




(73 




a £ 


















& 


a A 




cfl 




o 




P 


<u 


'"tf 


p 

z 

Id 


ft 




P 


£ cfl 
£ * 

tfl o 

.2) CD 
P 

o 


*d 


00 

p 


Cfl O0 


< 

as 


cfl 
oo 

in 

CD 
P 

*d 


Ph 

o 

p 

CJ 


2 g 

cfl "oo 
bJO p 
CD rv 
U ~* 

bfl 


n 


0) 


CD 


bJO 


S 


O 


0^ £ 


< 



X! 







00 


p 






a 


cfl 






!-. 


cfl 






O 


H-> 




cfl 




cfl 


tH 


CD 




p 


Cfl 


O 


o 




bJO 


cfl 




H 


-, 


n 


cfl 


bO 


> 


S-4 


> 


cfl 


0) 






CD 


P 




„ 


O 


o 






O 


< 






<J 



00 
CD • 

s 

CO .... o .S 

,P £ O 

°? u % 

i~! oo "p ^J 

'P * CD ™ 

^ "£ o v^ P 

CD fe -H O Cfl 

*» S ^ P 

p M p • 2 

2 5 Ss " | 
| s ? S - I : 

^ CD CD -tf - <jj 

'-U 

'Bn 

cfl 
O 









a. 


C^ 






cc 


C 


00 


>> 


cfl 


o 




,£3 


a 




^1 




CD - 


u 




D 


Ph - 




^ 


(h 


O 










u 


ffi < < 







Ph 




-■ 




Cfl 




CD 




Ph 


i 


cfl 




00 


00 




«3 

'Tr. 
o 




< 


: 


cfl 

a 


^ 




o 







'u 








Cfl 




a 




i3 


^4 


p 


cfl 


2 x o 


" 


O 'u u 


CD 


^ HJ ^ 


r] 


— cfl ii 


-i-j 


of nai 

ti in m 

in ai 


^ .a 


o . > 


bJO o 
P vs 


bo-B 2 


■ft g 

Ph a - 


efective 
vergrow 
ungus g 


verla 
iflam 


O w 


Q O fe 







oo 

'« 00 

■ • " 2 -a 

p cfl o s* bo a 



p 



C^Q 



• iJ p el S p a 

C) Oh O Ph < O O 



CLASSIFICATION. 105 




X 



o 

u 
to £ <D 

3 O rn 

o tf > 



u-l O J-i 

tfl • O • rt - 

5 £ O O !>, t« t tj 

<^ oj o ^OGjr^u 




feBJflfeO 



PART II.— SPECIAL. 



CLASS I. 

HYPER^EMI^— congestions. 

This class includes all cases of mere congestion of the skin; 
but while there are some, like erythema fugax, which are really 
only congestions, it includes others in which congestion is only 
a prominent early feature, as there are but few in which the 
process is not accompanied by inflammatory effusion, unless 
the primary congestion is speedily relieved. It is therefore to 
some extent a conventional class, in which congestion is the 
prominent, but not necessarily the exclusive manifestation. 

The clinical symptoms are — redness momentarily removable 
by pressure, generally increased heat of skin, which itches or 
burns slightly as a rule, and the seat of the lesion is manifestly 
superficial, i. e., in the papillary layer. 

The shape is indefinite and ill-defined at the border, the size 
from a mere point to a large patch, the evolution rapid, and the 
duration a matter of a few hours or days, unless the congestion 
limit has been passed and the disease has gone on to inflam- 
mation. 

Hyperemias are active or passive ; the active are synonymous 
with erythema, the passive with lividity of the skin. 

Passive congestion is idiopathic and local, due either to 
mechanical causes obstructing the venous flow, such as tight 
clothing or bandages, or to exposure to cold. Symptomatic 
disturbances in the circulation or respiration are more general 
in their action, and affect the peripheral circulation, especially 
the extremities, as in cyanosis from congenital heart disease or 
emphysema. 

I know of only one acquired affection of purely passive con- 
gestion that would at all attract the special notice of the der- 
matologist, viz., congestive mottling in rings. One instance was 

107 



108 DISEASES OF THE SKIN. 

that of a child under Dr. Barlow at the Children's Hospital at 
Great Ormond Street, in whom, when the legs were exposed, 
purplish rings about an inch in diameter, with clear centers, 
appeared slowly on the thighs. Another instance of it was a 
man with locomotor ataxy, shown by Dr. Lees at the Derma- 
tological Society, on whose legs a similar phenomenon devel- 
oped when the legs were uncovered; the rings disappeared when 
the limbs got warm again. In two cases, both girls, recorded 
by Cavafy,* there was a similar, but persistent condition, though 
varying much in degree, cold being an aggravating feature, 
while it was very faint in warm weather. It disappeared on 
pressure, leaving slight pigmentation. Both upper and lower 
extremities were affected, and one girl had had rheumatic 
fever and was subject to " dead fingers." 

In Galloway's f case a woman of twenty-one had congestion 
of the whole skin from vaso-motor paralysis of the superficial 
cutaneous circulation. The slightest injury produced a serious 
lesion. 

ERYTHEMA. 
Derw. — 'EpvOtjjia, a blush. 

Synonyms. — Rose rash; Fr., Erytheme; Ger., Hautrothe. 

" Erythema " is the term used to express the clinical aspect of 
acute congestion, and may be defined as " redness of the skin 
which disappears for a moment upon pressure." Much confu- 
sion has arisen from its being employed indiscriminately for the 
symptom of redness, irrespective of the cause, and also for two 
groups of diseases — one the result of hyperemia only, of which 
erythema simplex is the type; the other due to actual inflamma- 
tion, of which erythema exudativum is the most important 
representative. Although they all have the name erythema, it 
does not imply any relationship beyond the possession in com- 
mon of the prominent clinical symptom of redness. 

Confusion can only be avoided by always using a specific title, 

*" Symmetrical Congestive Mottling of the Skin," Clin. Soc. Trans., 
vol. xvi., 1883, p. 43, with colored plates and references to Kaposi and 
Auspitz. In Brit. Jour. Derm., vol. vii., 1895, p. 88, he records a case 
with patches of redness. 

f Shown at Derm Soc, Lond. Reported Brit. Jour. Derm., vol. x., 
1898, p. 50. 



CONGESTIVE ERYTHEMA. 109 

when erythema is intended to represent a special disease. At 
the same time it must always be borne in mind that the line be- 
tween hyperemia and inflammation is a narrow one, and many 
of the affections which are here classed under hyperemia are 
only so in the majority of cases, while in others the process goes 
on to exudation. The distinction is, therefore, often one of 
clinical convenience rather than of pathological accuracy. 

A large proportion of both classes of erythema are of toxic 
origin, the toxin acting, in all probability, on the vaso-motor 
nerves. Hence these may be grouped with urticaria, many 
purpuric eruptions, and pellagra, and are angio-neuroses,* of 
toxic origin. 

Erythema elevatum diutinum and erythema induratum do not 
really belong to this group except in name. The nosological 
position of the first is doubtful, and erythema induratum is 
placed with scrofulodermia. 

ERYTHEMA HYPER^EMICUM. 

In this class swelling is absent or insignificant in the con- 
gested areas, and the tint of redness varies from the brightest 
red to a rosy or purple hue, according to the predominance of 
arterial or venous hyperemia. 

There are two groups: I. Those of local distribution, due to 
external irritation; 2. Those of more or less general distribu- 
tion, due to internal causes. 

Group I. includes E. Simplex, E. ab igne, E. Pernio, E. Inter- 
trigo, E. Leve, E. Paratrimma, and E. Fugax. 

Erythema Simplex is the congestive redness due to external 
irritation of moderate intensity. 

The size and tint of the red patches vary according to the 
irritant, the individual susceptibility, and the activity of the cir- 
culation. The symptoms are generally a sense of heat, perhaps 
tenderness and itching of varying intensity. 

Etiology. — The causes are very numerous, and may be ar- 
ranged under the heads of: 

*T6r6k, in Archiv f. Derm. u. Syfik., September, 1900, p. 243, after a 
long review, concludes that no actual line of demarcation can be drawn 
between angio-neuroses and inflammations. 



no DISEASES OF THE SKIN. 

1. Friction, or pressure of clothing. 

2. Heat, whether of the sun (E. Solare) or artificial (E. ab 
igne). 

3. Cold, of which pernio, or " chilblain," is a familiar example. 

4. Stings, e. g., of the jelly-fish. 

5. Various irritants — vegetable, such as arnica, rhus, mus- 
tard, chrysarobin, etc.; chemical, e. g., acids, alkalies, sulphur, 
arsenic, mercurial inunction, etc. 

Erythema ab igne.* — This affection is important chiefly as a 
matter of diagnosis. It occurs in cooks, stokers, and women 
who toast their legs at the fire. In the early stage it forms 
rings of erythema and gyrate patterns on the front of the legs, 
and in one of my cases they were on the forearms and hands 
also; she used to sit over the fire with her elbows on her knees, 
resting her chin on her hands. The rings are from an inch to 
an inch and a half across, not elevated above the surface; the 
border, one-eighth to a quarter of an inch wide, of a deep red 
color, gradually becomes browner in tint, and when the legs 
have not been exposed for some time to the fire the redness 
fades and leaves only a deep brown, ringed pigmentation, which 
even the late E. Wilson * erroneously ascribed to syphilis. In 
exceptional cases, in the early stage, there may be vesica- 
tion on the erythema, following the ringed shape. Perry 
regards the lesion as essentially caused by the staining of blood, 
disintegration occurring in and around the walls of the plexus 
of superficial veins, and the patterned appearance as due 
to the distribution of these veins. In this he follows Wilks, 
who compared it to post-mortem staining. In a case Perry 
showed at the Dermatological Society an unusual feature 
was that the markings were distinctly raised, which he 
ascribed to thickening of the walls of the superficial veins. 
This and the occasional presence of vesication also show 
that blood-staining is only part of the process, and that 
his proposal to substitute ephelis for erythema ab igne is not 
an improvement. No treatment is required. The only thing 
to do is to avoid the cause, if not necessitated by the occupation. 

* Author's Atlas, Plate XXII., Fig. iv., shows the early stage with 
vesication in a marked degree. 

f " Portraits of Skin Diseases" — Melanopathia Syphilitica, Plate XXIV. 



CONGESTIVE ERYTHEMA. m 

In long-lasting cases the pigmentation is permanent, but fades 
to some extent in the summer. 

Erythema Pernio. Deriv. — 'IlTepva, the heel. Synonyms. — 
Pernio; chilblain; Fr. Engelure; Ger., Frostbeule. 

Symptoms. — People with a feeble circulation (see p. 62) or of 
strumous constitution, and many young people up to about 
twenty years, and a few older ones, are very liable to chilblains 
in the winter, especially in damp, cold w T eather: they are much 
less likely to occur in dry, cold weather of greater severity. 
They commence as ill-defined erythematous patches on the 
hands and feet, especially the heel and borders of the feet; the 
redness has generally a dusky hue, and is accompanied by ten- 
derness and intense itching and burning whenever the feet get 
warm. If neglected, or subjected to friction from the boots or 
stockings, more distinctly inflammatory symptoms arise, affect- 
ing the tissues more deeply; and vesication and superficial ulcer- 
ation of an indolent character, and even a small slough, may 
ensue. In persons * of very feeble circulation, where often the 
whole extremity is blue from venous congestion,* the chilblains 
may occur in comparatively warm weather. The only condi- 
tion that is likely to give rise to error is lupus erythematosus, 
which sometimes affects the fingers, chiefly the terminal pha- 
langes, as a permanent erythematous blush; in it, however, the 
duration will be a test, and it persists in summer as well as in 
winter; moreover, it is not attended with the itching and burn- 
ing of chilblains, and there is inflammatory infiltration, with 
more or less scaliness, followed ultimately by superficial 
atrophic scarring, but it is not liable to break down and ulcerate. 
Audry says that pin's-head-sized brown spots often follow chil- 
blains. 

According to A. E. Wright chilblain subjects have defective 
blood coagulability, taking from eight to twelve minutes 
(three to four minutes is the normal), and pernio is especially 
likely to occur in childhood and in those subject to urticaria and 
epistaxis, to the " lymphatic habit," to malaria and hemophilia, 
all conditions of diminished blood coagulability. Except as re- 

* According- to Leslie Roberts, injections with the old tuberculin may 
produce or aggravate chilblains. 
\ Lancet, January 30, 1897, p. 303. 



ii2 DISEASES OF THE SKIN. 

gards the blood coagulability, he does not bring forward much 
clinical evidence of these conditions as etiological factors. 

Treatment. — In this prevention is emphatically the best treat- 
ment, and may generally be effected by wearing warm coverings 
to the affected limbs, with thick boots, not spring-sided, and by 
active exercise, such as vigorous walking, running, or skipping 
for children. 

The hands should be washed in very hot water, not warm, 
dried very quickly and carefully, and then enveloped in gloves. 
General measures of invigoration are often required, and 
Fowler's solution in small doses, commenced as soon as the 
cold weather sets in, is said to be a prophylactic. 

I have found nitro-glycerin of more service; a tablet, three 
times a day for an adult, facilitates the circulation through the 
congested area, and is valuable both as prophylactic and 
curative treatment. Wright, to improve the coagulability of 
the blood, gives chlorid of calcium from ten to fifteen grains 
three times a day with, according to him, marked effect both on 
the blood and chilblains. 

Remedial Treatment. — Internally, opium was recommended by 
Skey. Nepenthe, five to fifteen minims three times a day, is a 
convenient form of it. Ichthyol in capsule three times a day is 
said to be effectual. 

Locally, at the commencement, calamin lotion should be ap- 
plied several times a day; afterwards tincture of iodin, painted 
on, for the feet, or decolorized with one part of liquid ammonia 
to two parts of tincture of iodin for the hands, is useful, but 
vasogen iodin rubbed in is better; it is effectual and does not 
stain. Equal parts of lin. camphorae comp. and lin. belladonnas 
well rubbed in twice a day, or careful strapping, or wrapping up 
the foot with cotton wool under a bandage, are also efficacious; 
so, too, is the old woman's remedy of soaking the part in very 
hot brine. Ointments of ten per cent, of ichthyol, menthol, or 
chlorinated lime and vaselin are advocated. Forbes Ross ad- 
vocates a strong Faradic current for ten minutes three times a 
day; and Lewis Jones the electric bath for ten to fifteen minutes 
a day. Two metallic plates as electrodes to an induction coil 
are placed at the ends of an earthenware footbath filled with 
warm water. 

When the chilblain is broken, boric ointment, spread upon 



CONGESTIVE ERYTHEMA. 113 

lint, or wet boric lint covered with oiled silk, should be applied; 
but, above all, rest and general warmth are necessary. Many 
other methods have their advocates; but if the preventive meas- 
ures are simultaneously practiced, and one of the above reme- 
edies perseveringly applied, they will be successful in giving 
relief, but any relaxation in the prophylactic means will soon be 
followed by a return of the chilblains if the weather is cold; 
hence the large number of " infallible cures " for this common 
and tormenting affection. 

Erythema Intertrigo. — Deriv. — Inter, between; and tercre, to 
chafe. Synonyms. — Intertrigo; Eczema intertrigo. 

Symptoms. — Some class this with eczema, but by most it is 
admitted to be an erythema. When in a fat person or in an in- 
fant two adjacent parts of the skin are in constant contact, the 
friction, the moisture, and the heat of the parts are apt to give 
rise to a superficial redness, together with an exudation of a 
thin muciform or purulent fluid, which differs from eczematous 
fluid, inasmuch as, while it stains, it does not stiffen linen, but 
a true eczema develops not unfrequently. In adults it occurs 
almost exclusively in fat people at the groin, axilla, or neck, but 
sometimes at the prepuce or vulva, and under the breasts in 
women. In infants it often occurs in the folds of the neck, but 
it is most frequent about the buttocks,* and there is no doubt 
that the irritation of the wet napkin, whether from urine or 
feces, is often the exciting cause, and among the poor some- 
times, from the urine-soaked napkin being simply dried and 
used again. The mothers often ascribe it to " thrush," which 
has " gone through the infant." Many of these cases are really 
due to congenital syphilis. 

According to Parrot there is transitory vesiculation like 
sudamina at the commencement, and superficial erosions fre- 
quently ensue. I have seen the erosions, but not the vesicles; 
and if they have been there they are seldom present when the 
child is brought. 

Diagnosis. — In adults it has to be differentiated from eczema. 

* Hodara has written a paper on the " Histology of Erythema of Infan- 
tile Buttocks," and gives references to several French writers with whom 
it is a favorite topic. — Monatsh. fiir Derm., vol. xxvi. (1898), p. 325. 
Also French Trans. Mai. Cut., vol. xi. (1898), p. 465. 



ii 4 DISEASES OF THE SKIN. 

The difference in the' exudation, the position, and circum- 
stances under which it occurs, are sufficient generally to deter- 
mine the nature of the lesion, but in some cases eczematous in- 
flammation actually supervenes. 

In infants the buttock eruption has to be distinguished from 
congenital syphilis, which often manifests itself as erythema of 
the buttocks ; but whereas intertrigo is almost invariably limited 
to the site of the napkin, the erythema of congenital syphilis ex- 
tends down the legs often to the heels and soles, and ulceration 
and other signs of syphilis would generally be present; at the 
same time it must be borne in mind that congenitally syphilitic 
children are more liable to ordinary intertrigo than others. 

Max Meyer thinks he has found the pathogenic micrococcus. 

Treatment. — In adults dessicating powders should be freely 
dusted on to the affected parts, and a piece of lint placed so as 
to separate the two surfaces, or the powders may be placed in 
Unna's powder bags (see p. 88). Good applications are oxid 
of zinc, one part to three of starch, or one part of oleate of zinc 
to three of kaolin, finely pulverized; and powdered boric acid 
diluted with kaolin, or the Sanitary Rose powder, is also useful. 
In a few cases powders do not suit as well as an ointment, and 
then boric acid gr. 20 to 3 j adip. benz. or vaselin is a good 
application. In others the lactate of lead lotion, constantly ap- 
plied, is one of the best. In infants, especially with diarrhea, 
care should be taken that the napkins are changed at once when 
wetted, the parts cleaned and carefully dried, and the powder or 
ointment applied; in these cases the ointment is preferable, as 
the moisture less easily affects the greasy skin. In all cases 
the parts should be sponged twice a day with a weak disinfectant 
solution. Lysol 3 i, aquae distillse 5 viij is a good example. 
Diarrhea and other defects of health must always receive special 
attention. 

Erythema Leve is applied to the redness frequently seen in 
edematous limbs, and occurs chiefly on the legs; here there is 
of course swelling from the anasarca; the skin looks bright red, 
tense, and shining, and there is, no doubt, more than mere 
hyperemia; unless the tension of the skin is soon relieved, vesi- 
cation and ulceration, and even sloughing, may ensue. The 
term is not so often used now as formerly. 



CONGESTIVE ERYTHEMA. n 5 

Erythema Paratrimma is an almost obsolete term for the 
erythema over a bony prominence, etc., that precedes the forma- 
tion of a bedsore; here, also, the process soon goes on to in- 
flammation. 

Erythema Fugax is, as its name implies, a transitory red- 
ness of a patchy character, which comes out quite suddenly, 
mostly upon the face or trunk, chiefly in the young, and after 
lasting from a few minutes to a few hours gradually disappears. 
In children it is frequently associated with irritating ingesta, 
worms, or other cause of irritation of the intestinal canal. Get- 
ting heated by exertion, or alternations of temperature, or even 
mental emotion, will sometimes produce it, but the cause is 
often obscure. The affection is more allied to urticaria than to 
the other erythemata. 

The treatment is conducted upon the same principles as that 
for urticaria, which see. 

Erythema Urticans is only the early or subsiding stage of 
the urticarial wheal, which is then of a uniform pink color. See 
Urticaria. 

Group II. — This group, according to the definition, would in- 
clude many of the exanthemata, such as scarlatina, measles, 
rotheln, beri-beri, etc., and such diseases as pellagra, but the 
eruption in most of them is the least important element, and all 
but the last are formed into a separate group on other grounds. 
It includes also the eruptions produced by many drugs in cer- 
tain individuals, from some special idiosyncrasy, but all these 
are referred to under their appropriate heads, and some de- 
scriptive adjective is usually added to point out the character of 
the erythema. 

The varieties now to be considered are E. roseola and E. 
scarlatiniforme. 

Erythema Roseola. — Roseola is a term used by some authors 
to designate some forms of erythema which are of not quite so 
bright a hue as the others. The distinction is superfluous, but 
as the term is in common use it must be explained; if retained, 
it would be better to use it as a specific title to the generic 
erythema, or for general as opposed to local erythemata. It 
may be idiopathic or symptomatic. 



n6 DISEASES OF THE SKIN. 

Idiopathic Roseola occurs mainly among infants and young 
children. Its onset is generally attended with constitutional 
symptoms — a transitory elevation of temperature, sometimes 
amounting to three or four degrees, restlessness, quickened 
pulse, furred tongue, and perhaps some redness of the palate 
and fauces, but there are no catarrhal symptoms. After a short 
but variable period the eruption appears ; it may be general or 
partial, affecting the whole body or only a limb, the face or 
neck; it is very variable in size and shape, at one time in patches 
the size of the end of the finger, at another faintly papular, or 
it may be in rings or gyrate figures; it may come at one place 
and go at another, and so last several days. Willan gave sepa- 
rate names to some of these phases, such as R. infantilis, aesti- 
valis, autumnalis, annulata, but they are entirely superfluous, 
and have deservedly dropped into disuse. 

Etiology. — 'Though these eruptions are most commonly seen 
in children, they may occur in older persons, and both sexes are 
equally liable to them. In some children the eruption comes 
out every spring and autumn, and it often appears to be due to 
disorder of and absorption of some noxious substance from the 
alimentary canal. When seen in adults it has been ascribed to 
suppressed gout, changes of temperature, acidity, and many 
other causes, which are often merely an excuse for our igno- 
rance of its origin. 

Symptomatic Roseola. — This may be patchy or diffuse, 
morbilliform or scarlatiniform, and may occur either in the 
onset or course of a large number of febrile or other affections. 
As the rash is only a part of these diseases it does not require a 
separate description, the circumstances under which it occurs 
being of chief importance. 

Diffuse or large patches of erythema may precede or ac- 
company the outset of the more characteristic eruptions of 
vaccinia, variola, and less frequently of varicella; it may also be 
occasionally observed in the algid stage of cholera, in diphtheria 
and malaria; the last is sometimes called roseola fcbrilis. Less 
frequently the eruption in any of the above diseases may be 
scarlatiniform or morbilliform. This patchy erythema or an 
urticarial rash may also be seen in influenza and dengue, but in 
these scarlatiniform or morbilliform eruptions are much more 
frequent, and purpura occasionally occurs. Small patches the 



CONGESTIVE ERYTHEMA. 



117 



size of the end of the linger, of a dull red color, are the usual 
accompaniment of the onset of syphilis, and very often of 
leprosy; but, as a rule, the patches in leprosy are larger and 
persistent. 

It is a futile distinction to try and discriminate between mor- 
billiform and scarlatiniform roseola on the one hand, and 
erythema scarlatiniforme and erythema morbilliforme on the 
other. Simply a slight degree of lividity is more apparent in 
the so-called roseola, but this depends more on the individual 
than the cause. Similarly, the individual rather than the cause 
determines whether the rash shall be morbilliform or scarlatini- 
form, and indeed, whether there shall be any rash or none is 
often equally the result of idiosyncrasy. 

Erythema Scarlatiniforme is the form which the rash takes 
in the great majority of the cases. It may appear sometimes 
quite suddenly, punctiform, erythematous, and exactly resem- 
bling scarlet fever in most of its features ; but it does not begin 
in any special position, and it is common to find the eruption 
sharply defined in places, especially beside the nose if the face 
is attacked, leaving a tract of, by contrast, preternaturally 
white skin between the two hyperemic areas. In a large pro- 
portion of cases the face escapes altogether. The punctiform 
appearance is not always preserved, the redness becoming con- 
tinuous, and, as in other erythematous eruptions, the red skin is 
whitened for a moment when the finger is drawn across it. 
There is some constitutional disturbance, usually slight, the 
temperature being ioo° F. or 101 F., and sometimes higher, 
but soon subsiding, and the fauces are reddened more or 
less. 

If the general symptoms are severe, they are due to the dis- 
ease in whose course the eruption appears. The subsidence of 
the rash, which occurs in from two to six days, is usually, but 
not always, followed by desquamation, furfuraceous as a rule, 
but it may be free and in large flakes, according to the intensity 
and duration of the erythema. The special recurrent form is 
discussed separately. 

Etiology. — This is not always ascertainable, and such cases 
are euphemistically termed idiopathic. Besides the causes al- 
ready stated, it is seen not infrequently in the course of acute 



n8 DISEASES OF THE SKIN. 

rheumatism; in septicemic conditions, as after surgical opera- 
tions, but not often from this source, now that antiseptic pre- 
cautions have been generally adopted; where pus is shut up in 
a cavity, e. g., abscesses, tubercular peritonitis, and empyema, 
and associated with carbuncle, I have also seen a discoid 
erythema with this connection; in gonorrhea, even where no 
copaiba has been given; preceding, or in the course of enteric 
fever, according to J. W. Moore, at the end of the first or in 
the third week, the first being of vaso-motor origin, the second 
being septicemic; in puerperal women, and in children in the 
course of pneumonia, ague, and after diphtheria antitoxin 
serum; in uremia (see p. 59), and tuberculin injections (some- 
times morbilliform, or even patchy or urticarial). 

Berg * found that the normal serum of some horses would 
produce these rashes, but the analogy with tuberculin suggests 
that diphtheria toxin may be a potent factor. Moreover, such 
rashes occur in the ordinary course of some cases of diphtheria, 
and it is observable that in a large proportion of cases toxins 
are the probable cause, whether absorbed from within or from 
without the body. 

I have also seen it in sewer-gas poisoning with an ulcerated 
throat, commencing on a level with the nipples, sharply defined 
there, and spreading nearly all over the body, and in a case with 
artificial anus, auto-intoxication from the bowel was reasonably 
probable (Lepine and Moliere). I have also seen a typical mor- 
billiform eruption with congestion of mucous membranes, and 
fever preceded by a general corymbose urticaria, clearly traced 
to a mass of retained feces. Scarlatiniform eruptions are not 
uncommon after the use of enemata, and are probably due to 
the solution of the toxins by the enemata and their subsequent 
absorption. 

A precisely similar eruption occurs after certain drugs, espe- 
cially mercury, copaiba, quinine, belladonna, salicylic acid, etc. 
(see Dermatitis medicamentosa). In the latter class the rash is 
probably due to irritation of the alimentary canal acting re- 
flexly on the vaso-motor centers. It may also be produced by 

* In connection with this may be noticed Sheild's observation, that 
when the arterial blood of some patients dries on the skin, an erythema- 
tous spot follows and lasts for half an hour or more. — Brit. Jour. Der?n., 
vol. viii. p. 430. 



CONGESTIVE ERYTHEMA. 119 

external irritants, especially mercurial inunction, exposure to 
great heat, etc. 

Diagnosis. — This is obviously very important in such a rash, 
but not always easy, or even practicable. From a well-marked 
case of scarlet fever there would rarely be much difficulty; the 
fauces, though red, are not swollen; the typical strawberry 
tongue is absent; the temperature is rarely over ioo° F., and 
soon falls; the rash is often not general, perhaps limited to the 
trunk, with healthy skin between the erythematous areas, and 
the borders of the erythema are often sharply denned; the char- 
acteristic features of scarlatina would be absent, without which 
it is never safe to make a positive assertion that the disease is 
infectious. From mild cases of scarlatina some of the above 
criteria may fail, and then only time will clear up the diagnosis; 
meanwhile, isolation is the safe course. 

From Measles. — The morbilliform eruption may resemble the 
exanthem very closely, but it would often not begin on the fore- 
head, as measles does, and the rash would often not be general; 
the prodromata, coryza, and other general symptoms of 
measles, and Koplik's spots on the fauces would be absent. In- 
stead of the temperature continuing to rise after the eruption 
was out, as in measles, it would soon fall, and the patient would 
not be so ill, as in most cases of measles. 

From Rbtheln. — There may be much difficulty, as the elevation 
of the temperature is often transitory in both; but the sub- 
maxillary, occipital, and sterno-mastoid glands are nearly al- 
ways enlarged in rotheln, and not in the morbilliform rash. 
There might be evidence of other people being attacked, which 
would not be the case in morbilliform erythema. In a rotheln 
epidemic of a hundred cases, Harrison of Bristol met with 
thirty cases of general erythematous eruption as a sequel or 
complication. 

It must always be borne in mind that the diagnosis of all the 
exanthemata should never be made on the rash alone, and in- 
deed not on any one or two symptoms, as there is great varia- 
tion in the development of every feature of these diseases, as 
regards incubation, prodromata, and general symptomatology, 
and in doubtful cases a conclusion can only be arrived at by 
carefully weighing the symptoms as a whole, and noticing accu- 
rately how the supposed exanthem differs from the usual type, 



120 DISEASES OF THE SKIN. 

remembering that the more fully the rash is developed, the less 
likely are the other criteria to fail in a real exanthematous fever. 
Treatment. — Xo special treatment is required for the rash 
itself, which will certainly subside in a few days, but the general 
indications are to clear out the alimentary canal and to pro- 
tect the patient from alternations of temperature. If there is 
irritation or tension of the skin, calamin liniment or lotion 
would give relief, or the inunction of almond oil or other simple 
fat. Alkaline and bran baths, with friction, facilitate the com- 
pletion of the desquamation. 

Erythema scarlatiniforme recidivans, or Recurrent Desquam- 
ative Scarlatiniform Erythema (Fereol, 1876). Under the 
name of Erythema scarlatiniforme desquamativum, Besnier, 
Brocq,* and other French authorities describe a relapsing form 
which is rare, but very important from the difficulty in diagnosis 
to which it may give rise. As far back as 1769- 1770 Warner 
of Guy's Hospital reported two cases to the Royal Society, and 
cases have been recorded under various names since; but it is 
to the above writers that we owe its clear differentiation. 
Brocq considers that it is a benign form of pityriasis rubra, but 
the fact that after each attack of erythema there is a single ex- 
foliation of large masses of cuticle, followed by branny desqua- 
mation for a few days only, marks it off from that disease in my 
opinion. 

The disease is probably due to toxins, possibly of more than 
one kind, absorbed from within, and some drugs, especially 
quinine, have seemed to be exciting factors of the first attack. 

The essential features are an erythema, diffuse or punctiform, 
which comes out suddenly, on the upper part of the body first, 
as a rule, and rapidly becomes universal, often within twenty- 

* And Besnier, " Path, des Erythemes," Ann. de Derm. " Desquama- 
tive Scarlatiniform Erythema," Amer. Jour, of Cut. and Ven. Dis., vol. 
iii. (1885), p. 225, gives a history and succinct account of the disease, also 
p. 26 of his handbook, 1892. Philosophical Trans., vol. lix. (1769), p. 281; 
and vol. lx. (1760). p. 451. L. I. Frank of Milwaukee records two cases, 
and quotes others in Amer. Jour. Cut. Dis., vol. xv. (1897), p. 116. One 
case was a quinine erythema, and not on all fours with this disease, but 
in the other case the first attack was excited by contact with rhus toxi- 
codendron, while the recurrences were not traceable to any special cause. 
Brit. Jour. Derm., vol. xi. (1899), p. 188, is a paper by myself relating two 
well-marked cases with comments. 



CONGESTIVE ERYTHEMA. I2I 

four hours. It is preceded and accompanied by more or less 
febrile disturbance. In three or four days the skin cracks and 
soon peels off in large flakes, or sheets, so that in some cases a 
complete cast of the extremities may be thrown off; the nails in 
one of my cases came away at a later period, and it also oc- 
curred in one of Warner's cases, but this, Brocq says, is excep- 
tional, transverse furrows only marking the attack and its re- 
lapses. Usually, also, the hair does not fall off. The peeling 
does not take place everywhere simultaneously, but in the order 
in which the different regions are attacked, the palms and soles 
being always the last to be complete. When what may be 
called the primary peeling is over, the skin is not at once 
smooth, a furfuraceous scaliness follows, and there is generally 
a horny plug at the follicular orifices, in some rjarts almost spiny 
to the touch, but the skin gets smoother almost every day until 
a relapse occurs, perhaps in a week or ten days from the onset, 
and again there is febrile disturbance and general erythema fol- 
lowed by desquamation, but the relapse is less severe than the 
primary attack. These relapses may be repeated many times, 
but the attacks as a whole generally terminate in six or eight 
weeks, and if there are no relapses in a week or ten days. A 
private patient of mine had four attacks of complete peeling in 
five years, the fourth after an interval of four years, the other 
three being in the first twelve months. There was only slight 
redness of the skin for three or four days before the peeling 
commenced, and no general disturbance. The redness always 
started on the left shoulder, which had been blistered a year be- 
fore the first attack. 

Recurrence is common, especially in rheumatic and albumi- 
nuric patients (Arnozan's case five times), and the recurrences 
take place at intervals of once or twice a year or more. One 
of my patients had five in seven years, while one of Tilbury 
Fox's * had nearly a hundred. Brocq says that the first is the 
most severe, and the succeeding ones become milder, but recur 
at shorter intervals ; but in a case of mine the reverse_ happened, 
the first being a mild one and the second and subsequent ones 
severe. The general symptoms vary considerably: lassitude, 
shivering, aching, and perhaps swelling in the joints and shoot- 

* Third edition, p. 25S. Probably this was only a.fa$on de parler, but 
it shows the recurrences were very numerous. 



122 DISEASES OF THE SKIN. 

ing pains along the limbs, with a rise of temperature from ioo° 
to 103 F., and occasionally slight redness of the fauces and con- 
junctivae precede the erythema for a few hours or days (three 
in a case of Brocq's), but soon subside after the eruption is fully 
out, and the patient ceases to feel ill, except for the burning, 
tension, and occasionally itching of the skin, when the disease is 
at its height. In a case of Carrier's * of Detroit pemphigus 
foliaceus developed, but as it only lasted two weeks this diag- 
nosis is questionable. 

Etiology. — The first attack occurs most frequently between 
thirty and forty, but no age is exempt. More men than women 
have been attacked, and Brocq says dry-skinned persons are 
more liable to it. My first case said that her skin had been 
rougher and drier, and that she had ceased to perspire after her 
first attack, so that possibly Brocq has mistaken the sequel for 
the cause. I had a patient in whom an attack of scarlatiniform 
erythema, with elevation of temperature and desquamation, oc- 
curred just after each of three successive confinements. In one 
of them a diagnosis of scarlet fever was made by a physician to 
a fever hospital. Possibly this is not quite the same as the other 
cases, and is more allied to the scarlatiniform eruptions not 
very rare after some drugs, such as mercury, quinine, etc., or 
they may be all of the same nature with different exciting causes. 
It is not improbable that all the cases, except those from drugs, 
are due to absorption of toxic products self-manufactured 
under varying conditions, at which we can at present only 
guess. 

Diagnosis. — The rapid and universal invasion with an erythe- 
matous efflorescence, followed by desquamation in large patches 
a few days from the onset, the tendency to relapse, and sooner 
or later to recur at intervals of months or years, are the most 
characteristic features. The chief difficulty would be to differ- 
entiate it from scarlet fever in some cases. In the absence of 
history of previous attacks the most important points are — the 
extremely short duration of the prodromal symptoms, the de- 
velopment of the rash not corresponding to the rule of scarla- 
tina, the temperature not being raised so much as would be ex- 
pected from the full development of the rash, if it were really 

* A. E. Carrier, " Proceedings of Michigan State Medical Society," 1889. 
His second case was possibly due to quinine. 



C0KGEST1VE ERYTHEMA. 



123 



scarlatina, and the abrupt commencement of the desquamation 
after three or four days in large flakes; and these would, if all 
the symptoms were taken together, render a decision possible. 
From the more typical form of pityriasis rubra, the non- 
persistence of the exfoliation in scales, and the relapses every 
few days, would make a differentiation, as well as the short 
course as a whole, whether with or without relapses. 

Treatment. — This is simple. A uniform temperature is im- 
portant, with rest in bed and locally inunction with olive oil or 
other emollient to relieve the tension of the skin. These are 
the chief indications. As the theory that the eruption is due to 
a toxin is very probable, full doses of perchlorid of iron might 
be administered. In one of my cases salicin appeared to check 
a relapse and there were none afterwards, so that it would be 
worth trying in future cases. 

Brocq includes as examples of relapsing desquamative 
erythema cases of the curious rare congenital condition called 
" deciduous skin " or keratolysis,* in which the person pos- 
sesses a skin which, like the serpent's, is cast off periodically, 
that of the limbs coming off like a glove or stocking. A case of 
a woman who had done this every month or six weeks from the 
age of seven if not earlier is recorded by Chevalier Preston of 
Canterbury, Xew Zealand, and another by Frank and Sandford 
of Chicago of a man set. thirty-three, who from the first year of 
his life had shed his skin on July 24. each year between the hours 
of 3 p. m. and 9 p. m. Constitutional febrile symptoms were 
experienced, and intense redness of the skin ensued; the whole 
process of exfoliation was completed in twelve days, while in 
early life it was completed in five days. I have met with a case 
of a man with tylosis palmae in whom every autumn the thick- 
ened skin was cast off, but the process occupied two months. 
Klotz reported a very similar case which recurred every spring 
preceded by nausea and pain in the stomach; this condition had, 
however, only been present five years. In Sangsters case, a 

* Literature. — I. Lci7icet, October 22, 1881, p. 703. — II. Quoted in Med. 
Press, September g, 1891, and republished as a fresh case by J. M. Sligh, 
International Med. Magazine, June, 1893; abs. in Brit. Jour. Derm., 
vol. vi. (1894), p. 30. — III. Brit. Jour. Derm., vol. iii. (1891), p. 172.— IV. 
Amer. Jour. Cut. and Gen.-Urin. Dis., vol. xi., 1S93, p. 30, he refers to 
Polotebnow's observations, Monat.f. Derm., 1887, Supp. — V. " Congenital 
Exfoliation of the Skin," Sangster, Brit. Jour. Der7?i., vol. vii. (1895), p. 37. 



I2 4 



DISEASES OF THE SKIN. 



man set. twenty-four, from the age of three years the skin was 
continually exfoliating, without any sign of inflammation, in 
large and small pieces everywhere, except the palms and soles, 
which were thickened and sodden from hyperidrosis. In hot 
weather he perspired in other parts of the body also. In addi- 
tion, he was subject to three or four exacerbations yearly, in 
which the skin peeled off like hop scales by handfuls every day. 
Sangster regarded it as clue to a congenital malformation. 
This case is allied to ichthyosis. 



CLASS II. 
EXUDATIONES— INFLAMMATIONS. 

The various forms of dermatitis constitute a large group, 
comprising many of the most important and common diseases 
of the skin, such as eczema, psoriasis, acne, and varieties of 
lichen. Such diseases as urticaria and pemphigus are also in- 
cluded, though Auspitz and some other dermatologists do not 
regard them as true inflammations; but the distinction is more 
theoretical than practical. Acne, sycosis, miliaria, and some 
others, though belonging to inflammations, are, for convenience' 
sake, described with the other diseases of the appendages of the 
skin. Inflammations of the skin are very diverse in their origin, 
course, and external manifestations, the one connecting link 
being the presence of inflammation in all of them. 

The symptomatology, also, is very wide, almost all forms of 
primary and secondary elementary lesions being present in one 
or other of the group. The process may single out one of the 
skin structures for its chief point of attack, or affect them all, 
or take only the superficial or the deep layers. Thus, while all 
layers may eventually be affected, in psoriasis the most con- 
spicuous changes are in the rete; in eczema, in the papillary 
layer; in carbuncle, in the deeper layers; in acne, the sebaceous 
glands are primarily affected; in lichen and sycosis, the hair 
follicles; in miliaria, the sweat glands or their ducts. 

A few, like erythema exudativum or herpes zoster, run a 
pretty definite course; but most, while they may be acute or 
chronic, tend to go on indefinitely, unless efficiently treated. 

ERYTHEMA EXUDATIVUM. 

This group includes E. multiforme, Herpes iris, E. nodosum, 
and Peliosis or Purpura rheumatica. 

They are all acute inflammatory eruptions, which occur in 
attacks, each running a short course, but with a strong tend- 

225 



i 2 6 DISEASES OF THE SKIN. 

ency to relapse (except E. nodosum) either at short or long 
intervals. They are characterized by symmetrical, raised 
lesions of some deep shade of red, extremely diverse in size, 
shape, and degree of elevation. Some or all of the lesions may, 
in certain cases, become vesicular or hemorrhagic. 

Erythema Multiforme.* — As its name suggests, this disease 
presents a most varied aspect, chiefly from differences in the 
size, shape, color, and aggregation of the lesions, but also from 
the occasional formation of vesicles or bullae upon, or the occur- 
rence of hemorrhage into, the primary lesion. To these 
phases different names have been given in past times, which 
will be explained in the description; they serve to express briefly 
the aspect presented at the moment to the observer, and they 
will, probably, be retained, as the eruption is often limited to a 
particular phase in certain individuals, and that, too, in every 
successive attack. 

Symptoms. — The onset of the eruption is usually preceded 
and accompanied by constitutional symptoms, slight as a rule, 
but sometimes of considerable severity. They consist of pains 
in the joints, and perhaps malaise, slight pain in the head, back, 
and limbs, gastric disturbances, and sometimes even enlarged 
spleen; these symptoms, with a temperature of ioo° to I04°.5, 
and a corresponding pulse rate, may lead to the suspicion of 
acute rheumatism. On the other hand, in many cases, some or 
all of these symptoms are absent, very slight pains in the joints 
being the most constant. After a varying interval of from a few 
hours to four days the eruption appears, usually upon the backs 
of the hands and feet, and subsequently in crops upon the face 
and rest of the limbs, rarely on the trunk, and it is especially 
abundant round the most painful joints. The temperature may 
fall upon the outbreak of the eruption, though it may keep above 

* Author's Atlas, Plates I. to III., illustrates E. papulatum, tubercu- 
latum, circinatum, iris (erythematous and vesicular), nodosum (forearm). 
A good plate of E. nodosum on the legs, Syd. Soc. Atlas, Plate XXI. 

Literature of Erythema.— Lewin, Berlin klin. Wochensch.,^o. 23, 1876, 
and Charite Annalen, Bd. iii. p. 622; Moritz Kohn (Kaposi), Archiv fiir 
Derm. u. Syph.,-vo\. iii. p. 381; Lipp, Archiv fiir Derin. u. Syfih., vol. 
iii. p. 221, Schwimmer, "Die neuropathischen Dermatonosen," p. 101; 
Osier, "The Visceral Lesions of the Erythema Group," Brit. Jour. 
Derm., vol. xii., 1900, p. 227. 



INFLAMMATORY ERYTHEMA. 



127 



the normal for some days, or it may continue to rise until the 
rash is fully out. 

The extent of distribution of the eruption is very variable, 
for, whilst it may be general, including and even commencing 
in the mucous membranes of the eye, tongue, and mouth, it is 
often limited to one or two regions; but whatever other parts 
may be affected, it is seldom absent from the back of the hands. 
Although symmetrical in the main, the symmetry is not abso- 
lute, the eruption being often more developed, or coming out 
earlier, upon one side than the other. 

It must not be supposed that the following description ap- 
plies to all cases; indeed, it is only in a very few that all forms 
can be found in the same patient; generally the eruption stops 
short at one or other phase, and then, after a short time, in- 
volutes without further development, and each succeeding at- 
tack generally recurs in the same form. E. papulatum and iris 
are the forms most frequently, and E. marginatum the least fre- 
quently, seen alone. Occasionally, instead of spreading by suc- 
cessive crops, the eruption of E. papulatum will come out sud- 
denly and extensively. 

The eruption commences in the form of groups of deep red 
papules, from a pin's head to a small split pea in size, slightly 
raised, and obtusely conical or convex (E. papulatum) ; these 
speedily enlarge, and if very closely arranged at first, they may 
coalesce into a slightly raised, deep red plateau or patch; or, 
if discrete, may enlarge to the size of a nodule or tubercle 
(E. tuberculatum or tuberosum) ; continuing to develop pe- 
ripherally, the center becomes depressed, of a purplish hue, and 
a ring is formed * (E. circinatum or annulare). As the effusion 
is absorbed in the center and spreads at the periphery, zones of 
color may be produced, varying from purple to pink, and con- 
stituting E. iris; still enlarging, and meeting adjoining lesions, 
the ring is broken, and gyrate curves are produced (E. 
gyratum). 

Closely allied to this is E. marginatum, which generally 
begins as a flat disc a quarter or half an inch in diameter, and 
very rapidly enlarges at the periphery, subsiding pari passu in 
the central older part; joining similar adjacent lesions, it forms 

*A very fine example is depicted in Plate XXIV., Sydenham 
Society's Atlas. 



128 DISEASES OF THE SKIN. 

a sinuous broad margin, abruptly limited externally, and slop- 
ing internally, rolling onwards, as it were, it traverses the cir- 
cumference of a limb, or a large area on the trunk, in a few 
days, leaving in its track fawn-colored pigmentation, which dis- 
appears very slowly. 

As the groups of papules come out in crops, each crop under- 
going similar changes, several of the various phases described 
may sometimes be seen simultaneously on different parts of the 
body, fairly earning Hebra's title of " E. multiforme." As acci- 
dental features, vesicles or bullae may form on any of the above 
lesions (E. bullosum), or hemorrhages may occur into them, 
and the affected extremities are sometimes livid and edematous. 
More or less brownish staining of the tissues is almost always 
left. 

Duration. — The duration for all forms appears to be usually 
from two to four weeks, but many cases by a close succession 
of attacks go on for a much longer period. Colcott Fox * 
records two cases in which a brother and sister had never been 
quite free from E. gyratum for sixteen years, the disease com- 
mencing in early childhood, and they had severe attacks every 
three months, with a constant succession of minor ones. These, 
however, were anomalous cases; and Pye-Smith,f who also had 
the cases under his care, took a different view of them. 

Children. — The general symptoms, especially the elevation of 
temperature, are often more marked. The lesions are apt to be 
more severe, and the contents, if any vesicles form, more apt to 
become purulent and leave scars. The eruption appears to be 
less frequently, simultaneously multiform. 

Etiology of Erythema Exudativum. — The frequency of all forms 
together is 11.4 per 1000. 

Age. — Though no age appears to be exempt, young adults are 
the most frequently attacked. The youngest case in my ex- 
perience was a case of E. papulatum in a child of five months; 
the oldest, an E. marginatum in a man of seventy-one years, but 
it is rare in elderly people. 

Sex. — The preponderance of evidence is in favor of all forms 

*C/m. Soc. Trans., vol. xiv. p. 67, with colored plate, and " Internat. 
Atlas," Plate XVI. 

f Guy's Hospital Reports, vol. for 1881. 



INFLAMMATORY ERYTHEMA. 129 

being more common in the female sex, though Hebra said it 
was most frequent in males. 

Season. — It is most frequent in spring and autumn, especially 
the month of April, but in many instances cold weather is an 
excitant. 

Previous attacks certainly predispose to others, and their re- 
currences tend to come out at the same time of year as previous 
attacks. Hebra says that roseola cholerica is really an E. papu- 
latum, that cholera is the only definite cause he knows of, and 
that it is never due to local irritation; but this is an error. I 
have had cases, in one of which exposure of the extremities to 
cold, in another exposure to the sun, and in a third exposure to 
brine-laden winds, were certain excitants for E. papulatum; one 
of these patients was a medical man, who was quite certain 
about its origin. 

Nevertheless, such instances are exceptional. Though un- 
able to get definite proof, I am strongly of opinion that sudden 
alternations of temperature, especially chills after having been 
overheated, are frequent determining influences, and that the 
rheumatic and gouty are more likely to be influenced by it. 
Lewin and Kaposi agree that irritation of the urethra, c. g., 
from gonorrhea or instrumental erosions, is another excitant, 
and Duhring thinks that irritating ingesta may produce it; but 
these cases are more probably urticarial. In a large number of 
cases no irritating or exciting cause can be discovered. 

Pathology. — Cordua and Luzzato have independently found 
cocci in the blood and lesions of patients suffering from erythema 
multiforme, and Manssurrow found bacilli and spores in four 
cases. These they believe to be the matcries morbi; and many 
writers, both in France and Germany, regard it as an acute 
specific disease, usually, but not always, of a mild type, founding 
their opinion on the frequent presence of premonitory symp- 
toms of a febrile character, the fairly definite course, and the 
occasional endemic outbreaks. These views require further 
proof before they can be definitely accepted, but they are worthy 
of consideration. Turning to the pathological mechanism of 
these eruptions, that they are not merely the result of hyperemia 
is evident even from their clinical features alone, and the anat- 
omy also shows that there is inflammatory effusion both of fluid 
and leukocytes. The fluid is usually only sufficient to push up 
9 



I3 o DISEASES OF THE SKIN. 

the epidermis into a papule or nodule; but in herpes iris, and oc- 
casionally in the other forms, it is in larger quantity, and forces 
its way between the rete cells and forms vesicles or bullae. 

Lewin,* Auspitz, and Schwimmer f consider them all angio- 
neuroses, and that the effusion is due to a vaso-motor disturb- 
ance when there are no febrile symptoms, and to true inflam- 
mation when general symptoms are present. That there is an 
escape of blood-coloring matter into the tissues is evidenced by 
the staining left after the departure of the rest of the lesion, and 
actual rupture of vessels and hemorrhage is the rule in peliosis 
rheumatica, and an occasional feature in all forms of erythema; 
in some of these hemorrhagic lesions sloughing occurs. 

Anatomy. — In a patch of E. tuberculatum:}: excised from the side of the 
neck of a man set. fifty-four (Fig. 10) I found the upper half of the corium 
broken up, and the space filled with cell infiltration, very dense in some 
parts and looser in others, as if separated by fluid. The cell infiltration 
sometimes extended sparsely to the bottom of the corium, especially 
along the hair follicles and sweat ducts, but it was, for the most part, 
confined to the upper half. In some places there was slight proliferation, 
and consequent thickening of the rete, and the palisade cells were stained 
with blood-coloring matter. There was no downgrowth of interpapillary 
processes, and the horny layer was unchanged. The changes, therefore, 
were essentially those of inflammation of the upper part of the corium. 

In the lesions of an E. papulatum of the back of the hands and 
feet in a case of severe diphtheric throat Finger § found edema 
with moderate mono-nuclear cell infiltration, especially in the 
papillary layer and in the deeper part in the course of the ves- 
sels and round the several glands and ducts. The papillary ves- 
sels were filled with streptococci pyogenes. 

Diagnosis. — The multiform and changing aspects of the erup- 
tion, the acute onset, the occurrence in crops, the localization to 
certain regions, the symmetry, the persistence for days of indi- 

* Berl. klin. Wochenschr., No. 23, 1876. 

f Schwimmer, " Die neuropathischen Dermatonosen," p. 101. 

% Leloir has also investigated the anatomy of this and some other forms 
of erythema. Abs. A?inates de Deri7i. et de Syph.^ June, 1885; and also 
Plates XIII. and XIV. of Leloir and Vidal, 1891. Ziegler describes a case 
of E. multiforme as due to streptococci from middle-ear disease, Path., 
vol. i. (1901), p. 601. 

§"Beitrag zur Aetiologie u. Path. Anat. des Erythema Multiforme," 
Archiv.f. Derm. u. Syph., vol. xxv. (1893), p. 765. Full abs. in Annates, 
vol. v. ^1894) p. 103. 



INFLAMMATORY ERYTHEMA. 



131 



vidual lesions, leaving staining behind, the comparatively slight 
itching, the tendency to recur at the same season of the year 
and to be associated with articular pains and febrile symptoms, 
are the most diagnostic features. It may be confounded with 
urticaria, rotheln, E. nodosum, and papular eczema. 

It is only when the wheals of urticaria are red or pink instead 
of white that any difficulty can arise; to the common white 
wheals there is no similarity. In urticaria the wheals are evolved 




Fig. 10.* — Erythema tuberculatum from the side of the neck, X 125. 
a, Epidermis; b b, round cells between the fibers of the upper half of the 
corium, which are widely separated, probably by serous effusion; c, 
blood-vessel; d, normal corium. The dark round bodies beyond d 
are transverse sections of muscular fibers. 



in a few minutes, are never such a deep red as in erythema, do 
not begin as papules and increase at the borders, but attain their 
full size at once, and are not symmetrically arranged; there is 
intense throbbing and itching, usually moderate in erythema, 
except in herpes iris, and it is rare for urticarial lesions to per- 
sist for more than a day, or to leave stains behind. There is no 
tendency to special localization and seasonal recurrence in urti- 
caria, and the outbreak can frequently be traced to irritating 
ingesta, though external influences play an important part; 
special constitutional symptoms are almost always absent, 

* The case from which this was taken is recorded by Tilbury Fox, Clin. 
Soc. Trans., vol. xi. (1878), p. 85. 



1 32 DISEASES OF THE SKIN. 

though a slight rise of temperature in very acute and extensive 
outbreaks may occasionally be observed. In the vast majority 
of cases reference to these points settles the matter conclusively, 
but sometimes there is a difficulty in separating urticaria from 
general papular erythema, as the evidence may be so evenly bal- 
anced that different observers may take opposite views. 

Rotheln is only to be confounded with E. papulatum. 

In both rotheln and erythema there may be transitory and 
moderate elevation of temperature, or none at all, but the other 
general symptoms are very different; catarrh of the pharyngeal, 
tonsillar, and other mucous membranes, with enlargement of 
the glands behind the sterno-mastoid, are present in rotheln and 
absent in erythema, and there are no special articular pains in 
rotheln. The latter eruption begins on the face and forehead, 
and spreads over the body. The spots are round or oval, not 
flat, generally remain small, and are of rosy red, never deep red 
like E. papulatum, and less frequently confluent. 

In eczema papulatum the papules are acuminate, small, and re- 
main so, and some of them usually become vesicular, while the 
burning and tingling is much more severe, and constitutional 
symptoms are absent. 

Prognosis. — The disease is almost sure to get well in from one 
to four weeks, leaving only stains, which disappear a few weeks 
later, except in the rare instances in which there are pustules, 
when there is likely to be scarring; all forms, except E. nodosum, 
are nearly sure to recur, probably at the same time, in the follow- 
ing year. When associated with endocarditis and the other 
serious conditions mentioned, the prognosis concerns the dis- 
ease with which the eruption is the concomitant, rather than the 
erythema. 

Treatment. — Since the eruption tends to get well of itself in a 
short time internal treatment is seldom required, and it is doubt- 
ful whether it has any direct influence upon the course of the 
disease; still, any indication in the shape of defective health 
should be carefully sought for, and if possible rectified. If the 
presence of a rheumatic diathesis can be established, salicin or 
salicylate of soda in gr. 15 doses three times a day, or an acetate 
and citrate of potash mixture might be given. An effervescing 
citrate of potash mixture with quinine gr. ij or iij in each dose 
of the acid portion is a good combination in many cases. In 



INFLAMMATORY ERYTHEMA. 



133 



middle-aged or elderly people gouty tendencies should be looked 
for and counteracted. In a large number of cases iron with an 
aperient, such as the elder Startin's mixture (Mixtures, F. 16), 
is useful. Iodid of potassium is considered to be a specific by 
Villemin; thirty grains a day cures it, he says, in three or four 
days. Locally, calamin lotion is all that is required, and if there 
is much pruritus the addition of liquor carbonis detergens gives 
temporary relief. In obstinate cases, when fresh crops keep ap- 
pearing, rest in bed, insuring complete protection from alterna- 
tions of temperature, is often sufficient of itself to terminate the 
eruption. When any debility is present careful feeding up is 
necessary, but alcohol is seldom desirable, and is generally 
contra-indicated. Relief from mental or bodily strain should be 
afforded as far as possible. 

In herpes iris the patients are often much out of health, and 
feel weak and languid, and then iron, quinine, and cod-liver oi] 
would be required. Locally, the itching and burning are best 
relieved by lead lotion, consisting of liq. plumbi subacetatis ti^xv 
to aquae 3 j ; or lactate of lead applied on lint. 

Erythema or Herpes Iris. — This is always an uncommon 
affection (1.6 per 1000), but the first variety is much more fre- 
quently met with than the second. The mechanism of erythema 
iris has already been described, but while the general history is 
the same as that of E. multiforme, its great variability of aspect 
necessitates separate description. 

In the usual types of erythema multiforme vesication is the 
exception; in these forms it is the rule; moreover, the varieties 
with which we have now to do seldom occur as a part of E. 
multiforme, but nearly always arise independently. The differ- 
ence of aspect between the simpler erythematous form and the 
vesicular form is so great at first sight that they were for a long 
time considered to be different diseases, but all intermediate 
gradations and their general behavior prove them to be only 
variations from a type. 

The common plan of all of them is a central lesion of papule, 
vesicle, or bulla, and one or more concentric circles round it; in 
Plate AZ of Wilson's Atlas no less than seven circles of fluid 
with intermediate purplish zones round a central vesicle are de- 
picted, while the simplest type is in Plate I. of my Atlas. In 



i 3 4 DISEASES OF THE SKIN. 

this there is simply a one-quarter-inch disc of erythema with a 
central purplish dot where the central papule subsided as the 
lesion extended peripherally. 

The commonest vesicular type usually begins with a stinging 
and itching sensation, soon followed by a small, slightly raised 
red spot, and upon this, in about twelve hours, a conical pin's- 
head-sized vesicle is formed. The vesicular part increases in 
diameter, flattening as it does so, but always with a narrow red 
areola on its outer border. When the lesion is about a quarter 
of an inch in diameter the fluid is absorbed in thexenter, and 
a purplish depression results, or a ring only of absorption 
occurs, and then a vesicle will remain in the center surrounded 
by a purplish depressed zone, and outside this a raised ring, 
white from the fluid beneath, and beyond this the narrow pink 
areola. This constitutes a typical patch, and it is from these 
different-colored concentric rings that the name of iris is de- 
rived. 

In a mild case, when the disc has reached to about half 
or an inch in diameter, which generally occurs in about a week, 
it soon begins to involute, the areola fades, the fluid is absorbed, 
and the disc flattens down, leaving only a purplish discoloration; 
the whole process being complete in about a fortnight. The 
favorite positions are the backs of the hands and fingers, espe- 
cially the thumbs, index and middle finger, the elbows and wrists, 
the insteps and knees. The lesions are generally symmetrical, 
though often the corresponding discs are several days later than 
the first, and are perhaps less developed. As the discs come out 
in small crops by repeated outbreaks, the disease as a whole lasts 
from two to four weeks, or even longer. 

Variations. — In more severe cases the patches may be much 
larger by the addition of a similar series of rings, or large irregu- 
lar patches may be formed by coalescence of neighboring 
lesions; the amount of effused fluid also varies considerably; the 
central small vesicle may develop into a large bulla, even up to 
an inch in diameter, and still larger by coalescence, and there 
may be hemorrhage into the bulla. Instead of being confined 
to the extensor aspect of the limbs, it may attack the palms, 
soles, and other flexor aspects, and also the face and the mucous 
membranes of the mouth, tongue, palate, and larynx, and in 
rare instances, the trunk also, so that universal herpes iris may 



INFLAMMATORY ERYTHEMA. 135 

result; in such severe cases hematuria * also has occurred. 1 
have also seen it all round and also under the nail,f but the nail 
substance was not affected. When it affects the mucous mem- 
branes J the lips may be much swollen, and covered with vesicles 
or black blood-crusts on the outside, and with muco-pus inside ; 
the mouth can scarcely be opened, the tongue is swollen, and 
covered with white lines, the remains of ruptured vesicles; the 
soft palate and uvula may be involved; the orbital connective 
tissue is swollen and ecchymosed, and there is conjunctivitis. 
In one of my cases the mouth alone was affected, attacks of bul- 
lous aphthae beginning on the buccal mucous membrane, spread 
over the tongue and mouth without any skin lesion, and re- 
curred every two or three months; after being under observa- 
tion for over a year, erythema iris appeared on the back of the 
hands in one attack, and the patient then remembered that he 
had had a similar attack some years before. Such cases are 
often treated for syphilis, and some are reported as buccal 
hydroa. Superficial ulceration occurs sometimes when the 
lesions are rubbed, to which the irritation experienced incites 
the patient, or when the contents of a bulla becomes purulent. 

The second variety is rare. The name of herpes iris was first 
given to it by Bateman,§ and hydroa vesiculeux by Bazin. In 
this round a central bulla a ring of vesicles is formed, either 
quite discrete or touching, but so that their separate origin is 
evident. The vesicles are about the size of a small split pea, 
much smaller than the one in the center. A second or third 
concentric ring of vesicles may form outside the first; between 
the vesicles and rings the skin is of a purplish tint. The fol- 
lowing case showed a slight variation from this description. A 
girl, set. two years, was brought to University College Hospital 
with rings of congestive erythema on the face and neck about 

* A case in the Vienna hospital, reported in Brit. Med. Jour. , July 10,1885. 

f Elizabeth M., out-patient, U. C. H. She had annual attacks for ten 
years. 

tU. C.H., out-patient Elizabeth J., set. forty-one, seventh attack; the 
mucous membranes were as described; round the knees were single and 
compound bullae, from half to two and a half inches in the longest 
diameter. Typical patches were present on the hands 

§ Bateman's Atlas, Plate LII. His plate has been repeatedly copied. 
Hebra's Atlas, Fasc. VI., Plate IV., Fig. 1, shows an extreme instance on 
the foot. 



136 DISEASES OF THE SKIN. 

the size of a crown piece; a few days later these had disappeared, 
and in the center of their site was a large bulla; round this a 
ring of discrete vesicles appeared, the contents of which soon 
became purulent, and when the dried scabs fell off the face was 
scarred as badly as if she had had smallpox; the child had sev- 
eral slight, almost abortive, attacks in subsequent years, each 
one slighter than the one before. This recurrence is the rule 
for all the varieties; the attacks are usually annual, and at about 
the same time each year, but some patients have three or four 
attacks per annum. 

It is sometimes associated with other forms of herpes, H. 
facialis, labialis, preputialis, etc.; and on this ground, and be- 
cause it is vesicular, Colcott Fox would separate this form; but 
its other features clearly designate it as belonging to erythema, 
in my opinion. 

Etiology. — The etiology of erythema or herpes iris is in most 
respects similar to that of E. multiforme,* but there is a smaller 
preponderance of females, 5 : 4 only in my hospital practice. 
Its tendency to recurrence is also greater. I have known 
patients who have had three or four attacks a year for twelve 
years; still, the majority of recurrences are in spring and au- 
tumn, though cold is a frequent excitant. In my experienc? it 
stands in closer relationship to gout than to rheumatism. Toxic 
influences also may sometimes produce it, but it is exceptional 
to be able to prove such to be the case. Thus, mercurial inunc- 
tion would always produce E. iris in one of Kaposi's patients, f 
and in another it was the prodromal eruption of variola. 

Anatomy.— Parder examined the lesions of a severe and a mild case 
and found an acute exudative inflammation of the upper part of the 
corium, accompanied by abundant emigration of polynuclear leukocytes, 
which rapidly disintegrated and filled the papillae. He lays stress on this 
nuclear fragmentation, which was less marked in the mild case. Vesic- 
ulation was produced by lifting up of the entire epidermis from the papillae 
by the fluid exudation, but Kreibich has shown that it is sometimes intra- 
epithelial. The appendages of the skin were unaffected.:}: 

Diagnosis. — This will not present difficulties in well-marked 
cases in which, symmetrically disposed on the hands, knees, and 

* For the Pathology, see that of E. multiforme, 
f Kaposi, p. 294, 2d German ed. 

\ J. C. Parder, in Bulletin Johns Hopkins' Hospital, vol. ix., 1898, p. 
165. Abs. Brit. Jour. Derm., vol. xi., 1899, p. 171. 



INFLAMMATORY ERYTHEMA. i 37 

insteps, there are several concentric rings of different tint round 
a central lesion, whether that be a purplish spot, a vesicle, or 
a bulla — and whether there are rings of fluid, or semi-confluent 
vesicles, or merely erythema without visible effusion round it; 
but there is a large proportion of cases in which there is only a 
central dot and a single broader ring of erythema round, as in 
Plate I. of my Atlas, or where there are other forms of ill- 
developed lesions when doubts arise. There are, however, al- 
ways some lesions on the plan described of one or more rings 
round a central lesion, and the general behavior will show that 
the eruption belongs to the E. multiforme group. In addition 
to vesication being so frequent a feature compared to other 
members of the E. multiforme group, articular pains and febrile 
disturbances are less frequent precursors of the eruption. 

Prognosis. — This is nearly the same as that for E. multiforme 
generally, but it seldom lasts more than two weeks, and it is 
even more likely to recur many times in future years. 

Treatment. — See under E. multiforme. 

Erythema Nodosum (Synonyms. — Dermatitis contusiformis; 
Fr., Erytheme noueux) is a disease of childhood and adolescence, 
being most common between five and twenty and rare after forty 
and under three years. It is seen much oftener in girls than in 
boys. 

It is still a matter of discussion as to whether E. nodosum is 
a variety of E. multiforme. Certainly, although second and 
third attacks do occur, they are the exception rather than the 
rule, as is the case in E. multiforme (6 cases in 108 had recur- 
rences, S. Mackenzie; none in 80 cases of A. J. Harrison). On 
the other hand, it occurs sometimes along with E. multiforme, 
of which I have seen a few instances. In one case there were 
E. tuberculatum lesions with it, and also herpes labialis. Lewin 
found other forms of erythema in 25 out of 55 cases; but this is 
not in accordance with usual experience, which is that such an 
association is an uncommon one. Perhaps the fact that when 
the lesions are not over the superficial bones they depart from 
the usual type may account for the discrepancy; nevertheless, it 
is sufficiently frequent to show that the different forms of erup- 
tion are related, and that E. nodosum is not an altogether inde- 
pendent type, as many authorities hold. 



138 DISEASES OF THE SKIN. 

McCulloch * gives a very well recorded case of the conjunc- 
tion in a boy of fifteen with a strong rheumatic family history. 
I have also had a case of a woman set. thirty-three, who suffered 
from E. multiforme of face and back, of forearms and hands, 
and as that faded, erythema nodosum developed on the shins. 

Symptoms. — It begins generally with articular pains in the 
lower extremities, with perhaps some febrile symptoms, an ele- 
vation of temperature of three or four degrees Fahr., seldom 
more, and highest in the evening, a furred tongue, and general 
malaise; but these symptoms, with the exception of the articular 
pains, may be quite absent. There is pain and tenderness over 
both tibiae, and in one to three days from the onset, roundish or 
oval, symmetrical, node-like swellings appear, with the long axis 
vertical over the tibiae. They come out two or three at a time, 
but are altogether not numerous, seldom more, and generally 
less, than a dozen. They vary in size, from a large nut to an 
egg, are not well defined, but diffused gradually into the sur- 
rounding tissues; they are tender and painful, rather firm at 
first, but soften, and become semi-fluctuating, but never sup- 
purate; their color is bright or rose red at first, but they soon 
get a more dusky hue, and as they disappear undergo the 
changes in color of a bruise. The eruption usually lasts eight 
or ten days, but, by the appearance of fresh lesions, may go on 
for two or three weeks. 

Variations. — The tumors may come over the ulnae, and I have 
seen them over the scapulae, the condyles of the humerus, and on 
the thighs. As a rule, these tumors are smaller than those on 
the leg. 

Duhring says E. nodosum may affect the mucous membranes, 
and in a boy aet. fifteen, under Fleming at U. C. H., there was a 
split-pea-sized subconjunctival nodule in the sclerotic of the 
right eye with typical E. nodosum on the legs. Uffelmann f 
and Oehne, quoted by Duhring, state that it is a bad omen when 
it occurs in children with a tuberculous family history, and that 
it is then associated with general tuberculosis. Amongst the 
many thousand children that have passed through my hands at 

* " A Case of Concurrent Erythema Multiforme and Erythema Nodo- 
sum," Lancet, April 20, igor. 

f Vierteljahr. fiir Derm. u. Syph., 1874, p. 174; 1877, p. 230; 1878, p. 
324- 



INFLAMMATORY ERYTHEMA. i 39 

the East London Hospital for Children, I have never seen any- 
thing to lead me to suppose that there is any connection between 
tuberculosis and E. nodosum; possibly some of their cases in 
this connection were really erythema induratum. 

Etiology* — S. Mackenzie collected 108 cases from different 
hospitals, and his statistics are therefore of interest and value. 

Sex. — He found 5 females to 1 male, Gorlitz f in 30 cases 
found 23 females to 7 males, i. c, only 3 to 1 ; and Harrison of 
Bristol in 80 personal cases found 3 to 1. 

Age. — S. Mackenzie found 69 out of 108 cases occurred be- 
tween ten and thirty, 14 under ten, 15 from thirty to forty, and 
10 over forty. Comby J met with a case set. fourteen months. 
In Gorlitz's statistics over half were under ten years and one 
was two years old. 

There is no special seasonal occurrence or recurrence. 

With regard to the relation of E. nodosum to rheumatism, 
S. Mackenzie came to the following conclusion: 1. That E. 
nodosum is frequently associated with definite rheumatic symp- 
toms, c. g., arthritis, sour sweats, sore throats, etc.; 2. That heart 
disease (endocarditis) may arise during an attack of E. nodosum, 
both in cases in which arthritis is present and in cases in which 
there is no affection of the joints; 3. That these conclusions 
justify the inference that E. nodosum is frequently, if not gen- 
erally, an expression of rheumatism, even when no other defi- 
nitely rheumatic symptoms are present. 

Harrison, on the other hand, denies its rheumatic relationship, 
and believes from his own experience that it never recurs. 
Gorlitz found endocarditis developing in 3 cases in the course 
of E. nodosum, and as antecedents he noted in 3 acute rheuma- 
tism, 1 measles, 1 diphtheria, 1 gastric catarrh, anemia in 9 and 
nothing at all in 15. It also occurs occasionally in the course 

* " On Erythema Nodosum, especially Dealing with its Connection 
with Rheumatism," by S. Mackenzie, Clin. Soc. Trans., vol. xix. p. 215. 
A valuable paper, with an analysis of 10S cases. Harrison of Bristol 
had 80 personal cases in 15,000 cases of skin disease, Brit. [our. Derm., 
vol. xii., 1900, p. 250. 

f Gorlitz, Munch, med. Wochensch., 1897, No. 46, p. 1286. Abs. Brit. 
Jour. Derm., vol. x., 1898, p. 31. 

% He read a paper on E. nodosum in infants at the Soc Med. des 
Hopitaux, reported with discussion Jour, des Maiad. Cut an., vol. ii. 
(1890), p. 356. He denies its relation to rheumatism or to paludism. 



i 4 o DISEASES GF THE SKIN. 

of secondary syphilis, but in these cases syphilis has probably 
only the same relationship as measles or acute rheumatism. 

Boiesco * of Roumania has found it to be common in children 
of from two to eight years old, exposed to malaria, especially as 
an immediate sequel of an ague attack; but this does not appear 
to be so common in other malarial countries,! so probably there 
are other factors. C. F. Moore of Dublin, from 12 cases in his 
own practice, shows that defective sanitation, especially as re- 
gards food and drains, is a strongly predisposing cause. Epi- 
demics of it have occurred. In 1858 Gall observed one in 
Bosnia among soldiers unaccustomed to the country I and bad 
food; in 1885 Brunn met with a small epidemic in Jutland, and 
Von Starck of Kiel observed it in sisters. Exposure to the same 
defective hygienic conditions accounts for these outbreaks with- 
out invoking the doctrine that it is an acute infectious disease, 
as Lewin, Lesser, Harrison, and several French writers suggest. 
Lannois,§ however, records an instance in which within a week 
of the entrance of a case of E. nodosum into a hospital three 
other patients in a row of beds opposite the first case developed 
the disease. Cases occur in association with " glandular fever," 
diphtheria, and other toxic diseases. ' H. Levy proposes to 
divide cases into primary, which comprises cases which are 
varieties of E. multiforme; secondary, occurring in the course 
of infectious diseases and due to toxins; and thirdly, toxic cases 
due to drugs, as iodids and antipyrin. The primary cases are 
also probably due to toxins, so that one and two need not be 
separated. 

Diagnosis. — In E. nodosum the oval tender nodes over super- 
ficial bones, like the tibia and ulna, may be mistaken for the 
nodes of syphilis. If, as occasionally happens, these occur in the 
early secondary period, when they may be symmetrical, red, and 
very tender, the similarity to those of E. nodosum may be great; 
but in such a patient the antecedent pains would have been 

*Abs. from Roumanian Archives of Medicine, Brit. Jour. Derm., 
vol. i. (1891), p. 34^- 

\ Moncorvo of Brazil only saw four cases of E. nodosum in a very large 
number of malarial cases. 

% It was probably acrodynia, as he confuses that disease with erythema 
multiforme. 

§ Annales de Derm., vol. iii. (1892), p. 585. 



INFLAMMATORY ERYTHEMA. 141 

severe, and the other symptoms of syphilis well marked, as they 
would never occur in a mild case. 

With regard to the nodes, so common in the tertiary period, 
the number would be less, except sometimes in congenital 
syphilis, the development is much slower, they would not be 
symmetrical, they would be harder at first, would not be red until 
they had been present for some time, and some evidence of past 
or present syphilis would doubtless be obtainable. In the rare 
cases of nodes in children from congenital syphilis there would 
be for a long period slow development and absence of redness, 
while the influence of iodid of potassium, a drug which has no 
effect in E. nodosum, would soon be manifested in nodes of 
syphilitic origin. 

The diagnosis from erythema induratum is given with the 
latter disease. 

Prognosis. — Recovery takes place nearly always in two or 
three weeks, and recurrence is rare. 

Treatment. — Internally, if there are febrile symptoms, the diet 
should be restricted to liquid nourishment for a few days. A 
saline aperient, followed by iron, the perchlorid preferably, is 
appropriate to a large proportion; or, in view of its frequent 
association with rheumatism, salicin, or salicylate of soda, gr. 
10 to gr. 15, according to age, three or four times a day, may be 
indicated. In older people anti-gout treatment or citrate of iron 
with citrate of potash or iron and aloes, or other aperients, are 
most suitable; but no routine treatment can be laid down. 

Locally, rest, with the legs elevated, should be strictly enjoined. 
In some adults who cannot lay up bandaging carefully, but 
firmly, with an elastic bandage (e. g., crepe) is the best substitute. 
One of the lead lotions just mentioned, applied warm, is usually 
most grateful to the patient. However marked the fluctuation 
may be, the nodes should not be opened, as absorption in- 
variably takes place. 

In a lady of fifty-five, where the pain was very great, the ap- 
plication of an ichthyol paint made by mixing 3 iij of ether and 
spirit, and then adding 3 ij of ichthyol, gave marked relief to a 
patient in the hands of Brownlie. 



142 DISEASES OF THE SKIN. 



ERYTHEMA ELEVATUM DIUTINUM. 

This disease does not belong to the preceding group, and is 
only placed here for convenience. The name only refers to the 
most prominent clinical features, and was proposed by Camp- 
bell Williams * and myself for a rare affection, chiefly of child- 
hood, of which we published a case in 1894. One had previously 
been published by G. S. Middleton in 1887, and by Judson Bury 
in 1889. A few other cases have been published since, and 
Hutchinson has recorded four cases of a somewhat different 
type, but closely allied in all probability. 

My case differs from the rest in the presence of erythema, its 
recent development (five months), and its involution. In all the 
others, except a case mentioned by Hutchinson, the lesions have 
been persistent. I only know of six cases excluding Soemmer- 
ing^. 

The lesions are nodules from a small pea to a bean in size, pink 
in the early stage, and purplish in those of long standing. Con- 
vex at first, they tend to coalesce into irregular lobed infiltra- 
tions and to flat raised plaques, but in severe cases distinct 
nodular tumors are present, even on the palms and soles. In 
Soemmering's \ remarkable case there were huge tumors pre- 
venting the hand from closing on the palmar surface ; Hutchin- 
son suggests that it should be reckoned in the same category, 
but it was such an anomalous case that it is better to keep it 
apart, at all events for the present. 

The growths are very firm to the touch and painless. They 
develop on the extensor aspect of the limbs over the articula- 
tions, elbows, knees, and phalanges of hands and feet. They 

* Literature. — A case of subcutaneous nodules in the hands of a 
rheumatic patient. G. S. Middleton, Amer. Jour. Med. Scien., October, 
1887. Williams and Self, Brit. Jour. Derm., vol. vi. (1894). p. 1. Colored 
plate and histology. Illustrated Med. News, February 23, 1889, and re- 
published in Hutchinson's Archives, vol. ii. (1891), No. 8, Plate LXI. 

Brit. Jour. Derm., vol. vi. (1894), P 144, by F. J. Smith, and p 148, 
also republished by Hutchinson in his Archives. 

Quinquaud has a model in St. Louis Museum, No. 1590, labeled 
" Fibromes multiples nodulaires des extremites, histologiquement 
fibromes facsicules." 

f Quoted and the illustrations copied in Hutchinson's Archives, vol. ii., 
1891, p. 299, Plates LX. and LXIII. 



INFLAMMATORY ERYTHEMA. 143 

also affect the palms, soles, and the buttocks and ears. In my 
case, and in White's quoted by Hutchinson, the tumors under- 
went involution, but in the others they were persistent for years 
and would probably be permanent on the hands. 

Hutchinson * has described a disease, of which he has seen 
four cases, which has some resemblances to the above condi- 
tion. The patients were all elderly men of florid complexion 
(the youngest was fifty-six), and all sufferers from chronic gout. 
The lesions were purple or plum-colored flat patches, much of 
which was due to venous congestion. The patches began as 
nodules, which became confluent, and their nodular origin was 
lost. The surface was smooth as a rule, but sometimes slightly 
scaly. Almost all the elevation disappeared by continued 
pressure, but they only paled at the periphery. The patches 
developed on the sites of pressure, e. g., inside the leg from 
saddle pressure or after injury, but had no selective affinity for 
the back of the articulations. They tended to spread and mul- 
tiply, and persisted throughout life, treatment having no effect 
upon them. (Compare with Kaposi's idiopathic pigmented 
sarcoma and Sequeira's f case.) 

Etiology. — This is remarkable; all but one were females, and 
all were children or young adults. Either in themselves or in 
their family history there was strong evidence of gout or acute 
rheumatism. Bury's case had intermittent albuminuria. 

Pathology. — They appear to be fibromata of inflammatory 
origin in the corium. The fact that many of the lesions involute 
is against their being true neoplasms. Probably they are 
analogues of the subcutaneous rheumatic nodules. 

Anatomy. — The histology of a lesion from the knuckle of Williams' and 
my case showed that the lesion was beneath the epidermis in the deep 
portion of the corium, all below the coil glands being normal. It con- 
sisted of a fibro-cellular structure, which in great part replaced the nor- 
mal fibers of the corium. The fibers followed the course of the vessels, 
being horizontal immediately below the papilla^ layer, vertical or oblique 
above, and branching horizontally below in the deep portion of the 
corium. The cells permeated the interstices of the fibers either singly 

* Illustrations of Clinical Surgery, Plate VIII., p. 42, Brit. Jour. Derm., 
November, 1888. " Symmetrical Purple Congestion of the Skin," 
Archives of Surgery, vol. i. p. 372. He refers to a case of Boeck's of 
Christiania, of which he has seen the drawing only. 

f Brit. Jour. Derm., vol. xiii. (1901), p. 2or, colored plate and histology. 



i 44 DISEASES OF THE SKIN. 

or in clumps, and formed accordingly a dense fibrous or loose fibro-cellu- 
lar structure. The sweat coils were very little, if at all, affected, and no 
hair follicles were found in the sections. In long-standing cases like 
Middleton's the fibrous tissue is more developed, and he found the coats 
of the arteries infiltrated with cells. 

Diagnosis. — Comparison need only be made with Hutchin- 
son's cases of purple congestion. The two types differ in the 
age and sex of the patients, in the position of the lesions, and in 
the older cases the nodular character was less developed, less 
firm, and were really edematous. They resemble each other in 
the gouty or arthritic tendencies of the patients, in the lesions 
being primarily nodular and becoming confluent into patches of 
a purplish tint. 

Treatment. — This is unsatisfactory. One case got well after 
taking arsenic and applying liquor carbonis detergens, so there 
would be no objection to trying them again, but it is probable 
that the result was merely a coincidence. 



PELIOSIS RHEUMATICA. 

Deriv. — IleXioS, livid. 

Synonym. — Purpura Rheumatica. 

Definition. — An acute disease, characterized by pain in some 
of the joints, accompanied by an eruption of red, raised patches 
or papules, which do not fade on pressure, or by purpuric spots. 

This affection, which is rather a rare one, was first described 
by Schonlein. It presents nearly all the characteristics of exu- 
dative erythema, except that the hemorrhages are a constant 
instead of an exceptional feature, and the joint trouble rather 
more severe than usual. I have therefore thought it more 
scientifically consistent to describe it with the affections with 
which its affinities are evidently of the strongest, than to follow 
the majority of authors, who place it under Purpura. 

Symptoms. — The patient complains of malaise, lassitude, and 
pains of moderate intensity in the limbs, especially the joints, 
which are often slightly swollen and tender. After lasting from 
a few days to a day or two, during the evening or night an erup- 
tion appears, and the pains then often abate. In many cases, 



PEL10SIS RHEUMATICA. i 45 

but not in all, the eruption is most abundant in the neighbor- 
hood of the joints in which the pain has been greatest, and upon 
the calves; the knees and ankles are always involved, the thighs, 
buttocks, elbows, and wrists frequently, the trunk rarely. 
Sometimes the order is different, the eruption preceding the 
pains. The skin lesions consist of slightly raised papules or 
patches, from an eighth to one inch in size, bright red at first, 
like an E. papulatum and tuberculatum, but unaltered by pres- 
sure, and soon becoming purplish; or they may be obviously 
hemorrhages from the first, and not at all elevated. Even pur- 
pura hemorrhagica, with all its various phenomena, may super- 
vene (Scheby-Buch) ; but this is very rare. A very severe case 
of this is recorded in full by J. Fayrer,* with extensive sloughing 
of the tongue, mouth, and penis, but the patient recovered; while 
S. Mackenzie, in commenting upon this case, relates another 
fatal case. These, however, run a somewhat different course 
to the milder and more typical forms, such as the second case of 
Mackenzie's. 

The temperature may be raised to ioo° F. or 102 F., but no 
relation to a fresh attack, the joint affection, nor the eruption 
can be established, the temperature being often normal, when 
all these phenomena exist in as great severity as in those in 
which the temperature is raised. In two or three days, or less, 
the pain subsides, while the hemorrhages * take the usual time 
for extravasations to undergo absorption. The attack may re- 
cur after an interval of from two days to two or three weeks. 
The same or fresh joints are again attacked, and the whole 
process is repeated, though sometimes with variations as to 
eruptions and pains, the disease dragging on in this way for a 
period of weeks or months. Purpura has been many times 
noted as a complication of acute rheumatism; but valvular 

* Literature. — Author's Atlas, Plate IV., Fig. i. " Clinical Lecture on 
Peliosis Rheumatica." By McCall Anderson. Brit. Med. Jour., vol. i. 
(1883), p. 1103. Fayrer, Brit. Jour. Derm., vol. viii. (1896), p. 73 illus- 
trated, and p. 116 for Mackenzie's article with a valuable analysis of 
forty-two cases of his own. 

f I have seen case of a lady of forty-five in whom all the symptoms 
above described occurred with a temperature of 102 F., followed by an 
erythematous papular eruption which did disappear on pressure; attacks 
recurred every three weeks for some months. They developed after 
influenza. 



i 4 6 DISEASES OF THE SKIN. 

murmurs * have originated in the course of peliosis rheumatica, 
and left permanent organic changes both in the valves and mus- 
cular wall of the heart, where there was nothing in the shape of 
high temperature, the severity of the articular lesions or sweat- 
ing, etc., to indicate that true rheumatic fever was present. 
Besnier and other French authors regard this as a proof that P. 
rheumatica sometimes has an etiological relation with valvular 
lesions. It may well be, however, that their relationship is only 
that of community of cause, and that is probably rheumatism. 

There is a form of purpuric erythema closely allied to purpura 
rheumatica which may be indeed identical as regards the rash, 
but the general symptoms are not so much arthritic as gastro- 
intestinal, the patient vomiting blood or passing it per anum. In 
a case under my colleague, Dr. Poore, which he asked me to 
see, — a man set. about thirty-five, — the intestinal hemorrhage 
was so great and uncontrollable that the patient nearly died; 
the rash was in purpuric papules about the elbows, knees, wrists, 
etc. In a girl set. thirteen, under me at Shadwell, the rash con- 
sisted of bright red papules all over the extensor aspect of the 
upper limbs, but somewhat dusky red in hue on the legs. They 
were flatly convex, not definitely circular; very abundant, but 
discrete on the arms above the elbow, but on the legs were in 
great part confluent. The whole of the rash, even where of the 
brightest red color, was unaffected by pressure. This was the 
fourth annual attack; the three preceding had been at or before 
Christmas, commencing with severe abdominal pains, vomiting 
and purging with blood in every motion and vomit, and the 
breath was very offensive. There was also hematuria, and more 
albumin than the blood would account for. The first and 
second attacks were the worst. The rash then was similar to 
the one I saw with Dr. Poore, but worse, the legs being swollen 
and painful; the ears had black blisters, and "the eyes turned 
black." The symptoms generally lasted three or four weeks, 
but on this occasion she had frequent recurrences, at short in- 
tervals, for six months. She was admitted to the hospital, and 
with rest in bed, tonics, and good feeding, rapidly recovered. 

* Wiener med. Wochensch., No. 32 (1883), p. ggi; Schwarz on two cases 
of P. rheumatica with acute aortic insufficiency, in Kaposi's Clinique. 
Abs. in Ann. de Derm, et de Syph., vol. v. (1884), p. 31. Also Oliver in 
International Clinics, vol. iv. — two fatal cases of endocarditis. 



PELIOSIS RHEUMATICA. l47 

It is to be noted that in these cases, while the visceral hemor- 
rhages are so profuse, those in the skin are quite moderate in 
extent, which constitutes an important distinction from purpura 
haemorrhagica of the ordinary type. 

A precisely similar eruption of varying grades of intensity, 
but characterized by the erythematous appearance and absence 
of alteration by pressure — in short, an Erythema haemorrhagi- 
cum — is more frequent without any general symptoms, or with 
slight pains in some of the joints or edema of the legs. Of this 
character is the eruption called by Hutchinson,* " purpura 
thrombotica." In some of the lesions the hemorrhage is suffi- 
cient to destroy the vitality of a portion of skin, and a slough 
ensues. When its mode of formation has not been observed, 
and the slough separates, the ulcer, in association with a red 
papular eruption which leaves stains, is strongly suggestive of a 
syphilitic ulcer. The mode of development of both sore and 
rash, and the absence of other signs of syphilis, will, if the ob- 
server is aware of this form of disease, suffice to distinguish it. 
I have had a case, sent me by my friend Dr. Coutts, of purpuric 
erythema multiforme in a girl of twelve, in whom, after pains in 
the head, knees, wrists, and ankles, a circinate and papular 
bright red eruption appeared on the extensor aspect of the limbs, 
unaltered by pressure. Two of the lesions consisted of two con- 
centric circles, and at the ankles there were irregular vesicles 
and bullae containing purplish serum. The rash is always worst 
on the legs. 

Etiology. — Women are more frequently attacked than men, 
say most authors, but Mackenzie's personal cases were males 
twenty-four, females twenty. It is about equally common in 
the second, third, and fourth decennia, but is rare under ten and 
over sixty. Eighteen out of forty-two had had rheumatic 
fever; and rheumatic subjects generally, as well as those who 
have had previous attacks, are more predisposed to it. In three- 
fourths of Mackenzie's cases the joints were swollen during the 
attack, and an even higher proportion were truly rheumatic. 
The season has an influence on some people; but of exciting 
causes little is known, except that chills appear to be the factor 
in many instances. Probably these only call into play " toxic 
influence." In a patient who played in an orchestra, whenever 

*Syd. Soc. Atlas, Plate XXXIX., and my own, Plate IV., Fig. 2. 



148 DISEASES OF THE SKIN. 

he was kept late, the next morning he had an outbreak on his 
legs. There was no other departure from health. 

Pathology. — The most probable conjecture is that it is due to 
the influence of a toxin, not necessarily always rheumatic, on 
the vaso-motor system, central or peripheral or both. The 
lesions are primarily like those of E. exudativum; but why in 
these patients hemorrhages should be a constant instead of an 
accidental feature, as usually obtains in erythema eruptions, is 
inexplicable, unless we suppose that the toxic influence is 
stronger in hemorrhagic cases; but then it would be stronger 
still in the less common event of hemorrhage being the only 
lesion. 

While it has so much in common with other forms of ery- 
thema multiforme as to justify its inclusion in that group, I 
agree with Mackenzie that its peculiarities make it recognizable 
as a special clinical type. 

Diagnosis. — The diagnosis presents no difficulty if the occur- 
rence of articular pains, with some swelling and a purpuric erup- 
tion, is sufficient; if. in short, joint pains and symmetrical pur- 
pura constitute P. rheumatica. It is, however, open to discus- 
sion whether all cases in which purpuric extravasation occurs 
in the course of acute rheumatism are to be placed in the same 
category, and also whether joint pains and cutaneous hemor- 
rhages may not be due to other toxins as well as those devel- 
oped in the rheumatic state. At present we are unable to dis- 
tinguish between them, but it is desirable to recognize that the 
most typical cases of peliosis rheumatica, in addition to the joint 
pains and purpura, run a protracted course from a succession of 
attacks at short intervals. It is also not improbable that the 
cases with purpuric rash and visceral hemorrhages which I have 
described, and to which Osier also has called attention, are due 
to the same toxins acting on different lines. 

Prognosis. — It is, in an uncomplicated case, quite certain that 
the patient will get well; it is equally uncertain when that will 
be, and it is highly probable that he will have another attack at 
some future time. In complicated cases the prognosis is that 
of rheumatic fever, endocarditis, or of other complications, such 
as the development into purpura hemorrhagica, when the extent 
of the hemorrhage into the viscera governs the prognosis. 

Treatment. — Rest in the horizontal position is important, get- 



PELLAGRA. 



149 



ting up too soon being alone sufficient, in many cases, to repro- 
duce the pains and purpura. Even when there is no definite 
evidence of rheumatic fever, salicylates often give decided relief 
to the pains, though they do not seem to have any influence in 
preventing the recurrence in a few days. Quinine and iron, 
separately and in combination, appear to be beneficial in some 
cases. The effervescing potash mixture, with full doses of 
quinine, is often of great value. McCall Anderson * treats it, 
like ordinary purpura, with turpentine or ergot. A liberal 
dietary is generally required, often with stimulants, and strict 
attention must be paid to hygiene and to the special indications 
of each case; but in many cases the disease runs its course unin- 
fluenced by treatment. 

PELLAGRAL 

Deriv. — ltd. Pelle, skin; Agra, rough. 

Synonym. — Span., Mai de la rosa; or, Mai roxo. 

Definifion. — An endemic tropho-neurotic disease of toxic 
origin, produced by diseased maize, and affecting the cerebro- 
spinal, digestive, and cutaneous systems. 

Pellagra was first observed in Spain in 173S, as recorded by 
Casal in 1762, and is now nearly confined to its northern part; 

*H. Miililbauer cured three cases quickly by giving salipyrin S 
grams a day, and one took 10 grams without ill effect. In the musician 
I have referred to Fowler's solution kept the disease in check as long as 
he took it. 

\ Literature. — Hirsch's "Geographical and Historical Pathology," 
Syd. Soc, vol. ii. p. 217, gives a very good account of the disease, to 
which I am much indebted. There is also a full bibliography, amongst 
which the writings of Lombroso and Roussel are most important. Paul 
Raymond's article, Ann. de Derm, et de Sypk., vol. x. (1889), p. 627, gives 
a good account of the skin symptoms, from which I have borrowed. 
Ludwig Berger — abridged trans, by Barendt, Syd. Soc. Trans., " Selected 
Monographs on Dermatology," 1893. Lombroso, " Etiological, Clinical, 
and Prophylactic Researches." German edition by H. Kurella, 1898, p. 
246. Full review in Brit. Jour. Derm., vol. x., 1898, p. 419. Sandwith, 
"Pellagra in Egypt." Read at Brit. Med. Assoc, annual meetingin 1898. 
Reprint, John Bale, 1899. Babes U. Sion. Die Pellagra, 1901. 

Tuczek of Marburg, " Klinische und anatomische Studien uber die 
Pellagra." Fischer, Berlin, 1893. Good review, in Annates, vol. v., 
(1895), p 187. 



*5° 



DISEASES OF THE SKIN. 



to Portugal; to northern and central Italy, especially Lombardy, 
Emilia, Venetia, and the south of Austria bordering on it; to 
Roumania and Corfu; and, until recently, to the southwest of 
France, but it has now died out there. All the affected districts 
are between 42 and 48 of northern latitude, in Europe, but 
Sandwith has shown that the disease is prevalent in Egypt as far 
as Assouan, so that the southern limit is 24 . Dr. Cuthbert 
Bowen of Barbadoes sent me photographs of erythema of parts 
exposed to the sun, and an account of symptoms which sug- 
gests that it is prevalent in that island; denudation of tongue 
and mucous membrane of intestine were present, but Thin says 
the disease was not " sprue." Sandwith states it occurs in India, 
though it is seldom recognized there, so that it is much more 
widely spread than was formerly supposed. 

Symptoms. — The symptoms, which are referable to the nervous 
system, alimentary canal, and the skin, almost always begin in 
the spring, with weakness, lassitude, giddiness, headache, articu- 
lar pain, severe burning sensation in the back radiating thence 
to the limbs, especially the hands and feet; the tongue is furred, 
the epigastrium tense and painful, and the bowels are loose, 
sometimes with slight jaundice. The skin is the last region 
affected, and is limited to the parts exposed to the sun, viz., the 
backs of the hands, forearms, and elbows, the face and neck in 
women and children whose faces are much exposed, and, when 
the person goes barefooted, the dorsum of the feet also, and 
occasionally the back and chest, being attacked in the above 
order. 

The distribution, says Paul Raymond, is very definite, as a 
rule, only on the back of the hand, not extending beyond the 
first interphalangeal articulation till late in the disease, and 
above, not beyond the back of the wrist, the forearm being only 
occasionally affected. Sandwith's Egyptian experience differs 
from this, the forearms and elbows being frequently involved. 
On the foot it only involves the upper half of the dorsum from 
the level of the malleoli, and only the front of the neck down to 
the first piece of the sternum, seldom the nucha. The erythema 
often develops suddenly within twenty Jour hours, and lasts 
from ten to eighteen days. It consists of diffuse, bright, dark, 
or livid red erythema, which disappears on pressure unless the 
congestion is so severe as to be hemorrhagic, for petechias are 



PELLAGRA. 



151 



common, and there may be bullae in rare instances also, which 
either dry up or rupture, or leave indolent erosions; the skin is 
swollen, tense, and burns or itches, especially the latter in the 
sun. In about a fortnight the erythema subsides, becoming 
dark in the center and laminaceous, seldom furfuraceous, des- 
quamation follows, leaving the skin beneath still thickened and 
more or less pigmented of a cafe au lait tint, or even sepia or 
dull brown; ephelides are also common. The thickening and 
pigmentation increase after each attack up to four or five years, 
when atrophy sets in. Then the skin dries, wrinkles, and 
withers like that of cachectic old age, and is so thin and lax 
that it can be pinched up as easily as it was difficult before. The 
nails and hair are unaffected. The skin manifestations thus, 
present three stages: (1) congestion; (2) thickening and pigmen- 
tation; (3) atrophic thinning. 

To return to the general course: 

After lasting up to July or August the symptoms decline, and 
the patient seems quite well in the winter, but in the next spring 
all the symptoms reappear, either with the same or greater 
severity, though sometimes the aggravation does not show itself 
until the third attack or later, when the patient is too weak to 
stand, emaciates, suffers from severe pains in the head and back, 
with tenderness near the dorsal vertebrae. Insomnia is frequent; 
the third nerve is paralyzed more or less, and in four out of five 
cases there are changes in the fundus oculi also. Sandwith 
found the knee jerks increased in the early stage, sometimes 
very marked, and at the late stage diminished and sometimes 
absent. Ankle clonus was absent, other reflexes followed the 
condition of the knee jerks. 

Meanwhile the rash may extend all over the body, with the 
changes already described, and the skin may lose more or less 
sensibility. The tongue gets denuded of papillae, red and dry, 
there is a burning sensation in the mouth, deglutition is painful, 
painless enlargement of the parotid has been noted by Sand- 
with, diarrhea increases to profuseness, all the cerebro-spinal 
symptoms, many of them meningeal, are aggravated, and the 
patient is delirious, sinks into a typhoid state, and dies. 

Mental depression, increasing to insanity, is very common, 
either in the form of mania, or that melancholia with fear of 
injury and a tendency to suicide by drowning, all pellagrous 



152 DISEASES OF THE SKIN. 

patients liking to see and touch water; or the patient may sink 
into utter imbecility; in the young it often takes a special 
form, in which the body and organs of generation are defect- 
ively developed, while the mental powers are precocious and 
active. 

Other less common symptoms are epileptiform convulsions, 
paresis of extensors, paralysis of the whole limbs and bladder, 
atrophy of the heart, alkaline urine of low specific gravity (1005), 
but no albumin, with dropsy and colliquative foul sweats, as 
well as the diarrhea. When the symptoms are not very severe, 
the disease may last ten or fifteen or even twenty years, but the 
average duration is five years. 

Etiology. — This may be summed up for Europe in the allitera- 
tion, Peasant life, Poverty, and Polenta, plus sun exposure as 
an exciting cause. Women suffer most and children least fre- 
quently, the commonest age being from thirty to fifty. In 
Egypt men are most affected, as they work most in the fields, 
and though maize is the staple food in Lower Egypt, they do not 
make it into polenta. In Upper Egypt, where millet is eaten, 
pellagra does not occur. It is a disease of the country, being 
only seen occasionally in towns, among the poorest and most 
exposed to the weather. The disease occurs almost exclusively 
(ninety per cent.) among the poorest peasants of the districts 
affected; but though it is predisposed to, and aggravated by 
poverty and bad hygiene generally, the immediate cause is the 
toxic influence analogous to ergotism, produced by eating de- 
composed or fermented maize, during which, as Lombroso's ex- 
periments show, a fatty oil (maize oil) and an extractive " pella- 
grozein " are produced, and the administration of these to men 
and animals excites pellagrous symptoms in them. The disease 
is not contagious, and is doubtfully hereditary, since both 
parents and children are subjected to the same influence. 
Sporadic cases are said to occur in France far away from the 
pellagrous districts, and it has been suggested that possibly 
other grains, such as oats, may undergo similar changes and 
produce similar effects. These are really, however, cases of 
what Roussel called pseudo-pellagra, which present to some ex- 
tent analogous symptoms. They occur in chronic alcoholism 
with peripheral neuritis, and in asylums amongst the demented 
and general paralytics. Leudet believes that there is a pseudo- 



PELLAGRA. 



1 53 



pellagra connected with poverty, but if so the disease ought to 
be universal. 

Pathology. — Lombroso infers, on good grounds, that it is due 
to a toxic effect on the cerebro-spinal nervous system, and 
Ferrati's * observations go to prove that the toxins are derived 
from mold fungi, and not from bacteria. 

The morbid anatomy shows four classes of changes : 
i. Hyperemias and inflammatory processes, leading to exuda- 
tion, etc., in the brain and cord membranes, liver, spleen, kid- 
neys, and lower part of the intestines. 

2. Atrophy and marasmus of the viscera supplied by the 
vagus, viz., the heart (brown atrophy), lungs, kidneys, spleen, 
and intestine, the muscular coat of the latter being- much 
thinned. In the Barbadoes cases the mucous membrane was 
denuded. 

3. Fatty degeneration of the kidneys, liver, myocardium, and 
of the vessels and cells of the spinal cord. 

4. Pigmentary degeneration of the cells of the brain, cord, 
liver, kidneys, and heart. The skin also is atrophied and pig- 
mented and often sclerosed, signs of senility in short. Yollmer 
lays stress on the horny metamorphosis of the rete. 

5. Special Cord Changes. — Primary lateral sclerosis in the 
dorsal region only; marked degeneration of the column of Goll 
in the median portion, except a small group of fibers imme- 
diately behind the gray commissure. Tuczek also found these 
changes, but says the posterior roots escape, while Lombroso 
found Burdach's column and the posterior roots sometimes in- 
volved. Unlike locomotor ataxy the lesion is seldom below 
the dorsal region, and Lissauer's tract and Clark's column are 
unaffected. Pellagra lesions therefore resemble those of gen- 
eral paralysis. In Egypt the post-mortem changes are com- 
plicated by the frequent presence of ankylostoma, bilbaria, and 
other parasites, and dysentery is not uncommon towards the 
end. 

Dejerine \ found parenchymatous neuritis of the cutaneous 
nerves, but this was a case of pseudo-pellagra in a chronic alco- 
holic. P. Raymond could find none in a true pellagrous patient 
with atrophic skin. 

* Abs. in Lancet, October 13, 1900, p. 1085. 

f Ann. de Derm, et de Syfik., vol. ii. (188 1), p. 719. 



154 DISEASES OF THE SKIN. 

Diagnosis. — This would turn on the position of the patient, 
exposing him to the influence of diseased maize or other cereal, 
the triad group of symptoms, depression, diarrhea, and der- 
matitis, the denuded tongue, tenderness of spinal nerves, the 
erythema being on exposed parts, and the general course of the 
disease. In pseudo-pellagra the erythema is present, but the 
other special symptoms and etiological conditions are absent. 
In alcoholic cases there would also be the symptoms of alco- 
holism, including peripheral neuritis as a rule, but in a case of 
Dubreuilh's it was absent. 

Prognosis. — This is only favorable if the attacks are of slight 
intensity, or if there has been not more than one previous at- 
tack, and the patient can be placed under favorable conditions. 
In other cases the outlook is very bad, and the nervous system, 
even at the best, is apt to be permanently damaged. 

Treatment. — Lombroso recommends for prophylaxis the bet- 
ter storing and gathering of the maize, so as to keep it dry * and 
avoid fermentative changes. Subsequently, when the disease 
has developed, removal into good surroundings, good feeding, 
and treating the patient according to circumstances; opium is 
recommended when there is fear or stupor; quinine in prostra- 
tion; calomel, arnica, and cold douches for diarrhea; but of all 
remedies, arsenic is the most effectual; 1-2 to 2 minims of liquor 
arsenicalis should be given daily; in infants, friction with chlorid 
of sodium is beneficial. 

Acrodynia or Epidemic Erythema \ is a disease closely allied 
to pellagra and ergotism, which occurred first in Paris and some 
other French towns as an extensive epidemic in 1828 to 1830 
and 1 83 1, and has since been observed on a small scale chiefly 
among Belgian and French soldiers and prisoners ; the last occa- 
sions being among the Mexican and Algerian soldiers in Mexico 
in 1866, and in one French regiment near Versailles in 1874. 

Symptoms. — The symptoms are those of gastro-intestinal irri- 
tation, redness of the conjunctiva, edema of the face, soon fol- 
lowed by formication, pricking pains in the palms and soles, and' 

* In Italy a kind of drying oven is supplied to the peasants by charity, 
and has been found to be a great aid in preventing the disease. 

f Hirsch, loc. cit., vol. ii. p. 248, contains the best account, of which 
the above is an abstract. Also Alibert, " Monographe des Dermatoses," 
2d ed., 1833, p. 12. 



URTICARIA. 155 

a burning sensation, with, at first, hyperesthesia of those parts, 
especially the feet, and later on, anesthesia; then an erythema- 
tous eruption breaks out, preceded by bullae, according to Ali- 
bert, chiefly on the hands and feet, but it may spread over the 
limbs and parts of the trunk, followed by exfoliation and dark- 
brown or black pigmentation, greatest in the warm regions of 
the body. In severe cases the limbs waste, become edematous, 
and there may be cramps, pareses, and toxic spasms. There is 
no fever, and it is seldom fatal except in the old and feeble, or 
occasionally from diarrhea; otherwise there is more or less com- 
plete recovery in a few weeks or months. There are no special 
post-mortem changes, and the pathology* is obscure, but prob- 
ably it is due to some defect in food, such as altered cereals, 
though this hypothesis lacks proof. 

URTICARIA. 

Deriv. — Urtica, a nettle. 

Synonyms. — Xettle-rash; Cnidosis; Fr., Urticaire; Ger., 

Xesselsucht; Xesselausschlag. 

Definition. — x\n eruption consisting of rapidly formed evanes- 
cent wheals, accompanied by burning and tingling. 

Urticaria is a common disease, probably much more so than 
statistics would suggest (44 per 1000). There are four principal 
varieties — U,. acuta, U. chronica, U. papulosa, and U. pig- 
mentosa; the last differs so much from the others that it is con- 
sidered separately. There are several subvarieties, the most 
important of which are U. tuberosa, U. bullosa, U. haemor- 
rhagica. U. factitia. and circumscribed edema. 

Symptoms. — In an ordinary case the eruption comes out sud- 
denly, either without any warning or preceded by burning and 
tingling of the skin, and sometimes by febrile symptoms. 

The lesions consist of firm, circumscribed, flatly convex eleva- 
tions of the skin, from a quarter to one inch in diameter, the 
general run being about the size of the finger-nail; they are at 
first red. and. as they develop, become white in the center, and 
only the border is red, or they may stop short at the red stage. 
In short, as their name indicates, thev are exactlv like the 



156 DISEASES OF THE SKIN. 

lesions produced by the nettle, urtica urens, and are called 
pomphi or wheals. 

Their formation and presence are attended with burning, ting- 
ling, and itching, sometimes slight, but usually so severe as to 
oblige the victim to scratch vigorously, the temporary relief 
thus obtained being purchased at the price of a greater liability 
to the formation of fresh wheals, which develop in a few minutes, 
last from an hour to a day, or even several days, and then dis- 
appear, without desquamation or other sign of their presence. 

The eruption is never symmetrical, the wheals have no defi- 
nite arrangement, vary from one or two to sufficient to cover 
more or less completely the whole body, including the mucous 
membranes of the mouth, tongue, pharynx, and inferably other 
mucosae, such as those of the air passages and stomach, dyspnea 
of spasmodic asthma type and vomiting having sometimes been 
associated with the skin eruption. Leube noticed it along with 
temporary albuminuria, and Gruss * relates a case in which 
acute orbital retrobulbar edema produced proptosis, and was 
associated with alarming cerebral symptoms. 

Variations. — Most of the subvarieties depend on the size, 
contents, and duration of the wheals, and a few on other con- 
siderations. The wheals may be very small, about one-eighth 
of an inch (U. papulosa), or they may be unusually large, as 
big as a walnut, hen's egg, or even larger (U. tuberosa, U. 
gigans,f Milton); these lesions are firmer and more persistent 
than usual, are few in number, and occur mainly in broken-down 
constitutions beyond the middle age. When the tissues of the 
affected area are lax, there is often much edematous swelling 
(U. cedematosa) ; this is well seen on the face, where the 
eves may be quite closed; the wheals here, too, generally remain 
pink throughout; the tongue may be so swollen as to threaten 
suffocation, but the swelling goes down in a few hours, and 
incisions are rarely necessary. A variety of this is the so- 

* In a discussion on Riehl's paper on " Circumscribed Edema "at Imp. 
Soc. Phys. of Vienna, reported in A T . Y. Med. Jour., 1887, p. 268. 

f Milton published a monograph on " Giant Urticaria "in 1878, in which 
he gives three cases. Juler relates one in Cinchinati Lancet and Ob- 
server, 1878; and Wilson one, 6th ed., p. 266. I have met with several 
cases. In one, a man set. forty-four, a broken-down publican, the wheals 
were sometimes as large as a goose's egg. He was also subject to diffuse 
swelling occupying nearly the whole anterior surface of the thighs. 



URTICARIA. 



*57 



called Quincke's disease, or, acute circumscribed or wandering 
edema, in which the orbital tissue or that of other parts of the 
face may swell up into a large tumor, or there may be a large 
ill-defined swelling of a great portion of the limb or other part 
of the body from subcutaneous edema. In these giant and 
diffuse forms, which seldom attack the trunk, itching is usually 
absent, but there may be burning and tension of the affected 
skin. Occasionally the subjective symptoms are present, but 
the wheals do not appear; this is the U. subcutanea of Willan; 
it is generally limited to the loins and thighs. 

Hemorrhage may occur into the wheals (U. hemorrhagica, 
or purpura urticans), and when the mucous membranes are 
affected may give rise to copious hemorrhage. Thus, Pringle * 
records a case of a gentleman of fifty, who had repeated attacks 
of alarmingly severe hematemesis, associated with outbreaks of 
urticaria of the body and visible mucous membranes; after two 
smart attacks of gout, the hemorrhage and urticaria, which was 
never hemorrhagic on the skin, diminished in severity, and be- 
came more amenable to treatment with subcutaneous injections 
of morphia and ergotin. In a boy of nine, under Murchison 
with U. tuberosa et hemorrhagica, there was hemorrhage from 
the bowels, kidneys, and urinary passages, and much uric acid in 
the urine. (See also Erythema haemorrhagicum.) Mackenzie 
met with a case of a boy of two who had a broad band of it 
round the abdomen after eating fried fish. 

When the serum which produces the wheal is more abundant 
than usual it may force its way up through the rete, and elevate 
the upper layers to a vesicle or bulla (U. bullosa). It is most 
frequent in children, and in one of my cases the contents became 
turbid, the bulla burst and left scars ; but it is a much rarer event 
than might be supposed. I have seen it simulate chicken-pox. 
Probably many of the recorded cases in adults were dermatitis 
herpetiformis, with which urticaria has close affinities; probably 
also crescentic urticaria is a form of hydroa. In one of my 

* Clin. Soc. Trans., vol. xviii. p. 143. In the Lancet, June 14, 1890, 
Wills relates two cases, one fatal. It was probably really a case of 
peliosis rheumatica. Chittenden's case was very like Pringle's, Brit. 
Joiir. Derm., vol. x., 1898, p. 15S. C. S. Hawkes relates an extraordinary 
case in a child of twenty-one months in which its life was endangered 
Abs. in Lancet, June 16, 1900, p. 1740. 



158 DISEASES OF THE SKIN. 

cases, a man set. twenty-eight, it began in rings the size of a 
shilling, which enlarged considerably on the palms, soles, and 
back of the hands. On the limbs and trunk were ordinary 
wheals, which also enlarged, and there was U. factitia. 

U. Papulosa. This is the form in which urticaria generally 
presents itself in children, and is the " lichen urticatus " of 
Bateman. It is due, doubtless, to the tissues of the child being 
more ready to resent irritation than those of adults. And, in- 
stead of there being merely serous, there is actual inflammatory 
effusion into the papillae, so that a papule is left after the wheal 
has disappeared. As usually seen by the practitioner, it is evi- 
dently an extremely pruritic eruption, suggestive of scabies, con- 
sisting of inflammatory pale red papules the size of a hemp seed, 
with scabbed tops. It is generally most abundant in an infant, 
about the loins and buttocks, but may be in any part which the 
child can reach to scratch. When present on the hands, the re- 
semblance to scabies is very close. Irregular flat scabbed pus- 
tular lesions (ecthyma) are often interspersed among the 
papules, and it is for this, frequently, that the child is brought; 
the wheals are often not present when seen by the doctor, and 
the mother generally says nothing about them unless they are 
inquired for. If they should happen to be present, they are 
often pink instead of white, and may be either of the ordinary 
size or very small, and sometimes are linear in the direction of 
the scratching. It is an extremely obstinate eruption, always 
worse in the summer. Hutchinson considers this disease to be 
entirely due to flea and bug bites and the like, in the first in- 
stance. I am convinced this is far too narrow a view, and that, 
though true of many cases, among the poor especially, irrita- 
tion of the alimentary canal plays quite as, or even more, im- 
portant a role in children than in adults, to say nothing of the 
other recognized causes of urticaria. 

Colcott Fox,* in an elaborate clinical essay on this subject, 
says truly enough that vesicles or pustules may be present in 
addition to the papules; but he is, I think, certainly mistaken in 
supposing that the papular, papulo-vesicular or pustular, or 
even bullous eruptions, which I have described in connection 

*" Urticaria in Infancy and Childhood," Brit. Jour. Deri7i., May and 
June, 1890. 



URTICARIA. 159 

with vaccination (see Vaccination Rashes) are only forms of 
lichen urticatus, though, of course, I admit that urticaria is 
sometimes a sequel both of varicella and vaccination. 

It is a moot point as to whether some cases of U. papulosa do 
not develop into prurigo (see that disease). 

U. Factitia exists where, owing to the excessive irritability of 
the cutaneous nerves, wheals can be excited by local irritation. 
This is the " dermographism " and " autographism " of fanciful 
writers. Letters can be inscribed with the finger nails or a 
pointed * instrument, and in a minute or two the white letters 
with pink borders stand out in bold relief on the skin; this con- 
dition can be produced even when the patient is under chloro- 
form (Caspary). The artificial wheals last from a few minutes 
to several hours, in rare cases eight to forty-eight (Barthelemy), 
but as a precursor of sclerodermia diffusa much longer duration 
has been reached. Bettmann f records that in a man set. thirty- 
nine it took several minutes to appear, and then remained un- 
altered for five or six days. The liability to it is also often very 
persistent, and may be associated with other forms. In fact, in 
most cases, at least a minor degree of it is present, and may 
sometimes be of diagnostic assistance. In the slightest form 
there is only redness without white elevation, in the line of the 
scratch like a tache ccrebrale. On the other hand Barthelemy X 
records a unique case in which white elevations without red bor- 
ders were produced by scratching. It developed on what he 
called a " nevrotoxidermite " of erythematous character ac- 
companied by intense irritation. In a case of Fabry's, § a woman 
of sixty-three, hemorrhage instantly ensued into the wheals, 
and remained for weeks after the subsidence of the wheal. The 

* Fereol met with a man who procured his admission to different hos- 
pitals by imitating the measles, scarlatina, or variola eruption by varying 
the instrument of irritation. 

f Bettmann, Berl. klin. Woch., April 8, 1901. Abs. in Brit. Med. 
Jour. Suppl., April 27, 1901, p 65. 

% P. 123 of " Dermographisme," Paris, 1893, an illustrated monograph of 
287 pages, copious literature, numerous cases, and an interesting history 
of the disease in the Middle Ages, when pseudo-miracles were worked 
on the patients by the priests. 

§ Archiv. f. Derm. u. Syph., vol. liv. (1900), p. in. Abs. Amer. Jour. 
Cut. Dz's., vol. xix. (1901), p. 112. 



,60 DISEASES OF THE SKIN. 

tongue was permanently swollen and protruded. Mouatt- 
Biggs * showed to the Clinical Society a very extreme case of 
the ordinary form, which appeared to have existed since birth. 
The patient was a noted athlete, aet. twenty-two, and showed no 
sign of nervous or arthritic diathesis, which Barthelemy thinks 
is the fundamental origin of the affection. In this case the hair 
follicles were so prominent and dilated that a fine wire could be 
introduced into them. The local temperature was raised, but 
there was no itching or ordinary urticaria. The lines traced 
reached their highest development in five minutes, remained at 
their height ten minutes, and disappeared in thirty to forty 
minutes. In a case of Thomsen's disease a pin prick produced 
a large wheal round the seat of puncture. The condition is not 
infrequent in locomotor ataxy, and in syringo-myelia. 

Confluent urticaria is U. conferta, and such terms as 
" ephemera " and " evanida " refer to the short duration of the 
wheals, and " perstans " when they last longer, with more hy- 
peremia than usual; it has, however, been used by some authors 
for U. chronica. Except U. perstans these terms are super- 
fluous and have fallen into disuse. In rare instances urticaria is 
distributed unilaterally. Thus in Rona's case, a girl of eighteen 
with acute rheumatism and endocarditis had left-sided urticaria 
and chorea, and in Mackenzie's case the distribution was over 
the left arm from the scapula to the wrist and confined to definite 
nerve tracts. Urticarial wheals present no definite grouping as 
a rule, but in one of my cases, a boy set. eleven, who had marked 
febrile symptoms from toxin absorption from scybala, broke out 
all over with corymbose groups of pea-sized wheals, followed 
the next day by a morbilliform rash. Urticaria may also be con- 
fined to a small area. In a man ?et. thirty-four I saw it limited 
to the palms, and it is often limited to the limbs, and in rare 
cases to a mucous membrane, e. g., tongue, larynx, etc.f 

U. Acuta is often, though not always, an U. febrilis ; when it 
is, the temperature may be raised 3 to 5 F. The pulse is quick, 
and there are marked signs of gastric irritation, nausea, vomit- 
ing, weight and pain at the epigastrium, furred tongue, pain in 
the head, and prostration. The eruption may not appear for a 

* Clin. Soc. Trans., vol. xxxii. (1899), p. 259. 
f Private note book G. Si 8. 



URTICARIA. 161 

day or two, and then comes out copiously all over; the gastric 
symptoms are temporarily relieved, the skin and gastric symp- 
toms alternating for some days; such cases are generally trace- 
able to a definite cause, and when they are due to irritating in- 
gesta, whether of food, medicines, etc., the eruption may follow 
the ingestion of the peccant material very rapidly, even while it 
is being eaten. When this is got rid of the urticaria rapidly 
disappears, but the gastric mucosa may be left in a very irritable 
condition, and many cases are probably due to auto-toxins. 

U. Chronica refers to the duration of the disease as a whole; 
the wheals come out acutely, and only remain a short time, but 
others form at either long or short intervals, and in some in- 
stances the interval is a regular one. Willan and Wilson both 
refer to cases of this type where there were outbreaks once every 
week; it is also seen in ague occasionally, but not following the 
intermittent course of the fever. The eruption is rarely so ex- 
tensive as in the acute forms, and there is less likelihood of there 
being general disturbance. The disease may last for an indefi- 
nite time, and though always relievable, is generally curable 
only with difficulty and perseverance. 

Urticaria perstans.* — While the transitory character of the 
lesions is the most striking and characteristic feature of the vast 
majority of cases, there are not a few in which either ordinary 
wheals remain longer than usual, or, while wheal-like in some 
respects, they differ in others and stay for days, weeks, or 
months, or there may be ordinary wheals which either develop 
into, or are followed by, lesions so different in character that 
their urticarial nature will be unperceived, unless their develop- 
ment has been observed, or that ordinary wheals develop from 
time to time as well as the persistent lesions, or unless urticaria 
can be factitiously produced by a scratch, to which the chronic 
lesion also responds by becoming hyperemic and more promi- 
nent. The most familiar secondary lesion is the persistent 
papule left by the wheals in children as already described under 
U. Papulosa. Hemorrhage into a wheal and simple pigmenta- 

* The author drew attention to these cases in a paper, " Urticaria with 
Persistent Lesions," in the International Congress at Rome in 1894, p. 34 
of Trans., relating several interesting personal and other cases. 
11 



162 DISEASES OF THE SKIN. 

tion following ordinary urticaria are also examples of secondary 
lesions, but more striking and important are the nodular lesions 
of infantile urticaria pigmentosa, to be described separately. 
There remain some rare cases, difficult to classify, which require 
brief mention. 

A Turkish bath attendant, set. fifty-four, came to U. C. H. 
with about a dozen lesions on each side of the chest and nowhere 
else. When they first came out they itched, w T ere white in the 
center, and round and prominent like a wheal, and then in a few 
days they settled down into flat infiltrations from a split pea to 
over an inch in diameter, firm to the touch, not sharply defined, 
and of a slightly livid red color and no itching. They remained 
thus for weeks or months, and then disappeared in four days 
from the beginning of involution. They had been present as a 
whole for a year and a half. In another case a woman, set. 
thirty-two, had similar lesions, except that some were hemor- 
rhagic, and persisted for weeks on the legs and arms. 

In a case of Morrant Baker's,* which he called U. perstans 
tuberosa, the patient, who had suffered from the disease for two 
years, had factitious urticaria, and in addition, persistent mottled 
yellow and red tubercles, affecting the whole of the ears, the 
knuckles, and elbows; they were said to have begun just like the 
wheals, and some had disappeared while others had come out. 
They were very tender, and one over a knuckle had ulcerated. 

A lady, set. thirty-five, was brought to me by Raymond John- 
son, with firm, solid tumors, some as large as a large goose- 
berry, which slowly formed (one six weeks) and then equally 
slowly disappeared. They were so like tumors that the question 
of excision had arisen. Urticaria factitia was present. 

At the Dermatological Society, October 14, 1891, Morrant 
Baker f showed a young woman, set. twenty-four, who for the 
last year had a disease consisting of pea- to bean-sized, convex, 
pale purplish-red, firm nodules, rough to the touch like flat 
warts. (U. perstans verrucosa). They had come out in small 
numbers at a time; but as each one persisted, when presented to 
the Society, they were pretty numerous on the limbs, more on 
the extensor than the flexor surface. She believed none ever 

* Med. Chir. Trans., vol. lxiv. (1881), with colored plate, 
f A wax model of this case is in the College of Surgeons' Museum, No. 
16 of Dermatological Series. 



URTICARIA. 163 

went away. They itched severely both during and after develop- 
ment. An early one, on the back of the hand, was of a brighter 
red and rather more acutely conical, and in the center was a 
horny dot formed round a follicle. Whilst under examination 
she scratched her forearm, and a distinct small wheal appeared. 
The general health was good. A verrucose case of this type 
was published by Kreibich * and others by J. V. Hielemann, and 
Johnston. 

In Penrose's case, f a child of two, the eruption followed 
measles, and some of the lesions lasted for months, one ten 
months, and was the size of half a crown, but most were from a 
hempseed to a shilling. They were red, smooth, firm, and deep- 
seated in rings and patches of hard nodules, and they did not 
itch much, and all but the oldest disappeared in nine months. 
These are only specimens of cases of which other varieties are 
scattered through dermatological literature. 

In rare instances the wheal may be limited to an appendage 
of the skin. Thus, under the name of urticarial acne, Lowen- 
bach X relates a case where the pilo-sebaceous apparatus was 
primarily involved. Intense itching preceded the appearance 
of firm pale red wheals from one-eighth to one-sixth of an inch 
across, which enlarged peripherally to one-fourth or one-half an 
inch and later underwent central disintegration and left a white 
cicatrix like that of acne varioliformis. The whole process 
lasted from four to six days. The affection developed after an 
attack of scabies cured by Peruvian balsam. 

Etiology. — No difference in age or sex brings immunity from 
urticaria, but it is more common in the female sex and in infants 
and children, in the latter mainly in the papular form, but 
U. bullosa is also more common in children; it is also more com- 
mon in the summer months. 

Foremost amongst the causes of urticaria in all forms is irri- 
tation of the alimentary canal, but the causes are so numerous 
that they must be classified into, first, direct or local irritation 
of the skin, and, second, indirect or reflex irritation. 

*Arch.f. Derm. u. Syfth., vol. xlviii. (1899), p. 165, colored illustrations 
and micro, section. Hielemann's case is quoted by American Medical 
Bulletin for May, 1900. Johnston's in Trans. Amer. Derm. Assoc, 1898. 

f Brit. Jour Derm,, vol. v. (1893), p. 210. 

X Archiv. f. Derm. u. Syph., xlix. (1899), P« 2 9- Full abs. in Annates, 
vol. x. (1899), P- IIoS - 



1 64 DISEASES OF THE SKIN. 

Under direct or local irritants come the common stinging-nettle, 
contact with medusae or jelly-fish, insect bites, e. g., of fleas, 
bugs, mosquitoes, bee or wasp stings, some kinds of caterpillar 
crawling over the skin, violent scratching from any cause, c. g., 
scabies or prurigo, and, occasionally, galvanic currents to the 
skin, poultices, etc.; sudden alternations of temperature, leading 
to chills, are also apt to produce it, much more frequently, I am 
convinced, than is usually supposed. De Argaez reports a case 
of a rheumatic woman who sat in a draught while perspiring, 
and an urticaria of the whole body ensued. In my own person 
a cold bath following immediately on a hot one produced gen- 
eral urticaria before I was dry. Direct exposure to intense sun- 
heat has also produced it, but this is rare. 

Indirect Irritation acts chiefly through the alimentary canal, 
which may be either healthy or unhealthy at the time. 

(a) Food, even articles not usually considered injurious, may 
excite it, but the more frequent are shell-fish, especially mus- 
sels * and crabs; some kinds of meat, especially pork and 
sausages; fruit, such as nuts, almonds, and strawberries; fungi, 
e. g., mushrooms; branny food, such as porridge or oatmeal in 
other forms, etc. 

(b) Medicines of many kinds, especially copaiba, cubebs, 
quinine, mercury even by inunction or subcutaneous injection, 
morphia, turpentine, salicylic acid, valerian, chloral, etc.; some 
consider that the occurrence of urticaria in ague is really due to 
the quinine given for the ague. Certain odors may excite it. 

(c) Worms are a common cause in children, but the main 
cause in them is chronic intestinal catarrh, commencing often in 
early infancy, and from want of efficient treatment persisting for 
years. The absorption of hydatid fluid, whether from spon- 
taneous rupture, puncture by trocar, or electrolysis, has re- 
peatedly produced urticaria; that it is not a reflex phenomenon, 
as Graham thought, was proved by Debove, who produced it 
by the subcutaneous injection of some hydatid fluid. Urticaria 
has also followed tapping an ordinary pleuritic effusion. A 
violent outbreak of urticaria has in a few cases preceded the 

*Schmidtmann found a ptomain he called " mytilotoxin " exclusively 
in mussels taken from impure stagnant water, and there is reason to be- 
lieve that it is the product of a bacillus, cultivations of which proved 
fatal to animals. 



URTICARIA. ^5 

exit of a guinea worm (Duke, Winze, Sutherland, etc.). Prob- 
ably both are examples of toxin absorption. Auto-toxins are 
probably frequent causes, but seldom demonstrable. Diph- 
theria and plague antitoxins, also, have produced urticaria. 

Langubuch, confirmed by Brieger, says that a living hydatid 
cyst contains a poison or ptomain, the quantity being in pro- 
portion to the activity of development of the cyst and daughter 
cysts. Succinate of soda is also found in hydatid fluid, and is 
another suggested cause of the eruption. 

In most of the other above instances there is a predisposing 
idiosyncrasy on the part of the patient, and most of them come 
under U. ab ingestis, as it is sometimes called, and refer to 
acute attacks. An extreme instance of predisposition is related 
by Buret. A man had urticaria of feet or hands whenever he 
washed them in cold water, while a flea drove him mad with 
wheals the size of a five-franc piece. In chronic urticaria, 
though many of the above agents will excite an attack, there is 
often defective digestion habitually present. The gouty diath- 
esis is a predisposing cause, probably by its association with 
acid dyspepsia; indeed, dyspepsia, however induced, is one of 
the commonest factors. Others are: 

Disorders in other organs, e. g., the uterus and ovaries, both 
functional and organic. Some women have urticaria just before 
each period, others have it at each pregnancy, others again dur- 
ing lactation. Leeches to the os, passing a sound, etc., are 
examples of direct irritation to the uterus causing urticaria. 

It is associated with many spasmodic conditions, e. g., 
asthma and gallstone colic; it is also seen in diseases of the 
nervous system, such as neuralgia, locomotor ataxy, and emo- 
tional conditions; thus I know of a lady in whom the advent of 
strangers produced urticaria, and this sensitiveness increased, 
until a knock or ring at the front door would determine an im- 
mediate outbreak; Alibert gives several analogous instances. 
Where bile is free in the circulation, as in jaundice, it is frequent; 
and in conditions short of actual jaundice, such as lithemia; it is 
not unusual in albuminuria and glycosuria also; and it has been 
found in association with rheumatism, purpura, and intermittent 
fever; in the latter case, it is often controllable by quinine. It 
is often difficult, especially in U. chronica, to ascertain the 
original cause, as it may date far back, and have rendered the 



166 DISEASES OF THE SKIN. 

vaso-motor system so irritable that the most apparently trivial 
conditions will lead to it; and the mental attitude of the patient 
towards those conditions which he knows will produce it is not 
unimportant. 

Pathology. — Everything in urticaria points to its being pri- 
marily a vaso-motor disturbance, direct or reflex, central or 
peripheral. The course of events is probably this: a spasmodic 
contraction is followed by a paralytic dilatation of the vessels, 
and stasis or retardation of the circulation in the papillary layer. 
Serous exudation then ensues, producing acute edema, which 
lifts up the epidermis into a wheal; this is pink at first, but as the 
fluid increases the blood is pressed out at the center, which be- 
comes white, while the periphery is all the more hyperemic. 

The arrectores pili are often excited to strong contraction, as 
in the instance of extreme U. factitia already related, and occa- 
sionally the wheal is limited to the hair follicle. 

It is supposed by many that the muscles of the skin, by their 
contraction, limit the edema and increase the prominence of the 
wheal. 

Philippson * disputes the vaso-motor view, and believes with 
Heidenhain that a secretory action of the vascular endothelium 
is involved, and that the process is a mild inflammation from a 
feeble toxin action. 

Anatomy. — Vidal f excised a wheal during life, and found the " super- 
ficial and deep network of vessels dilated and gorged with blood without 
any alteration of their walls. Both the blood-vessels and lymphatics 
were surrounded by leukocytes, which were also scattered through the 
whole thickness of the cutis and massed together at certain points. A 
few were to be seen between the cells in the deepest layer of the epi- 
dermis. Here this structure was normal, but another piece of skin was 
excised from a wheal in which the epidermis had been raised into a 
vesicle. This vesicle contained a sero-albuminous fluid and the debris 
of epithelial cells. In the middle layers the cells were vesicular, and 
those of the deeper layer granular. Leukocytes migrating among the 
cells in the deep layer of the epidermis were more numerous than in 
the other case." Neumann found a local edema and ischemia in a wheal 
produced on a rabbit with a stinging-nettle. Unna also has examined 

**' Experimental Researches on Urticaria." Philippson, Giorn. Ital. d. 
Mai. Veil, e d. Pelle, 1899, p. 675. Abs. Brit. Jour. Derm., vol. xii. 
(1900), p. 217. 

t L' Union Midicale, February 24, 1880; quoted in Lancet, vol. i. (1880), 
P- 537. 



URTICARIA. 167 

a wheal, and found edema of the lower layers of the cutis, forming fis- 
sures and loculi in the lymph vessels and spaces; he thinks the wheal is 
produced by a spasm of the large veins of the skin, which normally serve 
to carry off the lymph. 

Leredde * examined the blood in two acute urticarias and one 
chronic one with acute attacks. He found polynucleosis, dur- 
ing the attack, only with leukocytosis. As the urticaria sub- 
sided, so did the polynucleosis, and in one case was followed by 
eosinophilia. Lazarus also found sixty per cent, of eosinoph.'.es, 
and Leredde suggests that this examination was made as the 
attack was passing off. These observations, while requiring 
further research, suggest, Leredde thinks, that urticaria may be 
connected with an undue sensitiveness of the hemapoietic, rather 
than of the nervous system. 

Wright f finds that there is deficient blood coagulability in 
those liable to urticaria, and that this conduces to " serous 
hemorrhage," and gave twenty-grain doses of chlorid of calcium 
three times a day as a corrective successfully in two cases. 

Gilchrist J found an excess of indican in some cases of urti- 
caria, but he did not state whether constipation was present in 
those cases — a condition in which it is usually increased. 

Diagnosis. — The sudden evolution and transitory duration of 
white or pink, itching or tingling elevations, or wheals, are quite 
characteristic, and even when there is no eruption when the pa- 
tient is seen, an eruption which comes and goes at short inter- 
vals can scarcely be anything but urticaria. 

The eruptions most like urticaria are those of erythema papu- 
latitm or tuberculatum, which may resemble pink wheals; but the 
erythema is symmetrical, and seldom itches severely, and the 
lesions often enlarge peripherally, and in these points it differs 
from urticaria. 

Similar considerations would distinguish erythema nodosum 
from U. tuberosa; moreover, the tumors of E. nodosum are very 
tender. 

U. papulosa is very like scabies in its general aspect, but there 
are none of the characteristic burrows, and the eruption is not 
between the fingers, and often not on the other favorite seats 

* Annates de Derm., etc., vol. x. (1899), p. 403. 
f Brit. Jour. Derm., vol viii. (1896), p. 82. 
% Treuis. Amer. Derm. Assoc., 1899. 



1 68 DISEASES OF THE SKIN. 

of scabies. It must, however, be borne in mind that the two 
may be associated, and that scabies may lead to urticaria; a his- 
tory of urticaria is not enough, therefore, as it may be only 
secondary. Quite as often the urticarial element is overlooked, 
and it is only on inquiry that it is found that " the child comes 
out in bumps," or " water blisters," as if it had been stung by a 
nettle. 

The erythema stage of dermatitis herpetiformis might easily be 
mistaken for it; the crescentic arrangement of the lesions, which 
are always pink, their independence of ingesta, and the fact that 
vesicles or bullae develop sooner or later as the rule, while in 
urticaria they are exceptional, would guide to a correct decision. 

Prognosis. — Acute urticaria usually gets well in a few days or 
less, but some cases, if untreated, go on into the chronic form. 

The chronic form depends largely on the possibility of remov- 
ing or avoiding the cause or causes. 

The papular urticaria of children is often a very obstinate 
affection, even when it seems to be well in winter, breaking out 
again when the warm weather sets in. I believe, however, that 
all cases are curable, if the parents will be sufficiently watchful 
against exciting causes, and will persevere long enough with 
remedial, and above all with preventive, measures. 

Treatment. — An acute attack, due to irritating ingesta, is best 
treated by an emetic if seen sufficiently early, and at a later 
period, saline aperients, such as sulphate and carbonate of mag- 
nesia (Mixtures, F. I, 2, or 3). 

These measures are often sufficient, but where any gastric 
irritation remains care must be taken lest it lapses into the 
chronic form ; bland and unirritating articles of diet, an efferves- 
cing soda mixture, or mixture of bismuth (Mixtures, F. 10), 
would be the line to follow. 

For the successful treatment of chronic urticaria, the study of 
the etiology is the most important preliminary. This comprises 
not only the original cause, which may or may not be operative 
when the patient comes under observation, but also exciting 
causes of fresh outbreaks. Most careful inquiry into the habits 
of the patient, and the conditions under which the eruption 
comes out, should be made, the urine examined, and investiga- 
tion of every organ and its functions may be required. In the 
vast majority of cases, however, it is with the alimentary canal 



URTICARIA. 



169 



that we have most to do. The diet should be carefully regu- 
lated; fermentable articles, such as pastry, highly seasoned or 
sugared foods, beer, etc., avoided; alcohol should be very spar- 
ingly taken, if at all; pure, well-diluted spirits are the least in- 
jurious, and perhaps claret may be permitted; the patient should 
be instructed to notice if any special article of diet or other cir- 
cumstance leads to the outbreak. The bowels must be carefully 
regulated; an aloes, belladonna, and nux vomica pill every night 
is often most useful (Pills, F. 1 or 2), with occasional salines, 
such as Carlsbad Sprudel salt, or seidlitz powders; or alkalies 
with bitters, such as carbonate of soda and calumba; or bismuth 
nitrate and nux vomica (Mixtures, F. 8 to 10). Intestinal anti- 
septics often afford most valuable assistance. I cured a case of 
fifteen years' duration by persevering treatment in this 
direction. 

The gouty diathesis is a frequent offender; alkalies, with the 
other measures for that condition, may be needed. Diuretics 
are often required, and act most beneficially in some cases 
(Mixtures, F. 7). And yet, with every care, and when all the 
functions are duly performed, there are cases in which the erup- 
tion will continually recur. It is then that we must seek the 
help of those narcotics which act on the vaso-motor centers, 
such as the tincture of belladonna, in full and increasing doses; 
or, better, sulphate of atrophia, 1-150 grain cautiously increased, 
or pilocarpin 1-8 of a grain may be daily injected sub- 
cutaneously. Antipyrin or antifebrin in ten-grain doses will 
often cut short an actual outbreak, and is sometimes curative. 
It is often a good plan to give one or two tabloids a couple of 
hours before an anticipated attack, outbreaks in some patients 
recurring with something like punctuality. Phenacetin and 
trional are alternative drugs. Chlorid of calcium was recom- 
mended by Wright,* as already mentioned under Pathology, at 
first thirty grains twice or thrice a day, then twenty, and then 
ten. I tried it in a few cases, but without success, and in one or 
two the eruption came out more abundantly. In obstinate cases 
further trial might be made, but most cases yield to treatment on 
the general lines laid down. 

In infantile urticaria from chronic intestinal catarrh diet is of 
the highest importance ; sweets of any sort should be absolutely 
* Lancet, January 18, 1896, p. 153. 



170 DISEASES OF THE SKIN. 

interdicted, and starch cut down as much as possible; therefore 
no potatoes, toast instead of bread, and milk puddings of rice, 
etc., or sop, should only be permitted when mixed with maltine. 
All fruits, especially strawberries, should be avoided, except 
perhaps baked apples. A fair amount of meat may be allowed 
to a child two years old or more. 

For drugs, bicarbonate of soda and bismuth, with carmina- 
tives, salicylate of soda or salol, and sometimes gray powder and 
pepsin, are the kind of drugs most frequently indicated. 

In some of these apparently causeless cases a steady course 
of arsenic in small doses, long continued, has been most suc- 
cessful in my hands; but it must be given with discrimination, 
and never when the urticaria is connected with the disorder of 
the alimentary canal, as it will then only add fuel to the fire. 
Bromid of potassium has been strongly recommended by 
McCall Anderson. Quinine in full doses is also successful, both 
in malarial urticaria and some other cases, but it must be re- 
membered that quinine causes urticaria in a few persons. 

Galvanism down the spine cured a case in which it came out 
in the erect, and disappeared in the recumbent posture. Stro- 
phanthus, ichthyol, salicylate of soda, and iodid of potassium 
also have friends, but it is wiser to depend more on rational 
carefully planned treatment than on specifics. I believe, how- 
ever, in salol as an intestinal disinfectant in chronic intestinal 
catarrh, and in antipyrin to ward off attacks. Much depends 
upon how far the patient can or will co-operate. Thus, even 
apart from alcoholic habits, it is almost impossible to cure a 
cabdriver in cold weather. 

Local treatment is very important ; the irritation of the nails in 
scratching has a most injurious effect on the already irritated 
cutaneous nerves, and yet to tell the patient not to scratch is 
useless, unless relief is afforded in other ways. One of the most 
important preventives is the preservation of a uniform tempera- 
ture. 

The clothing and bedding also should be light and absolutely 
unirritating; at the same time the patient must be guarded 
against chills. Jacquet demonstrated the importance of this by 
preventing urticaria entirely in one part of the body by wrapping 
it in wadding. 

The same remedies do for both acute and chronic cases; alka- 



URTICARIA PIGMENTOSA. 171 

line baths, warm but not hot, with or without scalded bran, or 
starch, sulphid of potassium, or carbolic acid baths, are all use- 
ful (Medicated Liquid Baths, F. 1, 2, 6), but they must be used 
with care, as subsequent exposure to a different temperature 
will bring on an attack. Some forbid baths on this account. 

Dusting freely with flour relieves acute cases. Sponging 
with vinegar and water, or citric acid in chloroform water, have 
their advocates, but the best remedies of this class are, I think, 
the disinfectants. I have tried a large number, and they are all 
more or less useful. Foremost I would place liq. carb. deter- 
gens 3 ij or 3 iij to water § viij ; sanitas and water equal parts ; 
terebene 3 j to § viij; salicylic acid, made soluble with glycerin 
and borax, 3 ij to § viij ; benzoic acid in saturated solution ; 
carbolic acid 3 j or 3 ij to 3 viij; evaporating lotions of spirit 
and water; or spirit and lead lotion (Antipruritic Lotions, F. 20 
to 38); chloral camphor may be painted on, or camphor ball or 
menthol rubbed on obstinately itching spots. So many are 
mentioned because, in chronic cases, either they lose their effect 
after a time, or, what is more likely, the patient loses faith and 
wants a change, but the first two are my favorites. Acute cases 
yield most rapidly, and even the chronic urticaria of children 
may be temporarily held in abeyance by keeping them in bed. 

URTICARIA PIGMENTOSA (Sangster).* 

Synonym. — Xanthelasmoidea (Fox). 

This affection differs from ordinary urticaria in many ways, 
besides the presence of pigmentation with, or after, the wheals. 
As already stated, pigmentation occasionally follows ordinary 
urticaria in adults, and although thus entitled to the above name 
it would not connote the affection now under consideration, 
which with very few exceptions commences in early infancy. 

* Literature. — Author's Atlas, Plate VI., illustrates nodular or xanthe- 
lasmoidform. St. Louis Atlas, Plate XLIX. , shows the mixed type in an 
atypical form — Brit. Med. Jour., September 8, 1869; Clin. Soc. Trans., 
vol. xviii. (1885), p. 12 (case by the author, with analysis of previous cases 
and colored plate of the mixed form). Colcott Fox's essay in Med Chir. 
Trans., vol. lxvt. (1883), p. 329, gives abstracts of all cases up to date and 
microscopical diagrams. Paul Raymond, " L'Urticaire Pigmentee," 
''These de Paris," 1888, gives a complete resume — relates fully twenty 



172 DISEASES OF THE SKIN. 

The first case on record is Nettleship's (1869), and although 
there have been probably a hundred cases recorded since his, 
most of them in Great Britain, it is still a rare disease. I have 
had eight cases under my care representing the three types of 
the affection. These are: (1) The nodular, or xanthelasma id type, 
originally described by Tilbury Fox, which is the rarest form; 
(2) the macular, in which there is only pigmentation, without or 
with very slight elevation of the lesions, which Sangster 
brought into notice and gave the title which has been generally 
accepted for the disease as a whole, though it only fits this 
phase of it, and (3) the maculo-nodular, or mixed type, which from 
its frequency and its containing all the elementary lesions may 
be taken as the most representative form and will be considered 
first. 

Symptoms. — The eruption begins in the first six months of 
life, and is most abundant on the neck and trunk, next upon the 
limbs, face, and head, and only occasionally on the palms and 
soles; but no part of the body surface is exempt, and it has been 
observed on the palatal, buccal, and pharyngeal mucosae. It 
commences by the formation of nodules or wheals, which are 
formed rapidly, often appearing in the course of the night, and 
are arranged singly, or in groups of three or four. In Hallo- 
peau's case they were in oblique rows in the line of the ribs — a 
proof, he thought, of a nervous distribution and origin; but, in 
my opinion, only due to the lines of cleavage in which the 
blood-vessels run. 

At first they are about the size of a small split pea, distinctly 
and sharply elevated above the general surface, and of a yellow- 
ish-red color, with a narrow pink areola; subsequently they in- 
crease in size, sometimes by coalescing, and some of them may 
become of a distinctly yellow or buff color; these, while they re- 
semble a wheal in form, approach a xanthoma nodule in color, 
but are firmer, and rarely of so bright a yellow. As fresh lesions 
are forming every few days, there may be seen simultaneously, 

nine cases. Doutrelepont, Archiv. fur Derm. u. Syph., vol. xxii (1890), p. 
311, gives references to several other recent cases besides his own, and re- 
ports of cases are now too numerous to specify, but L. Blumer, in Monatsh. 
f. prakt. Derm., vol. xxxiv., 1902, No. 5, p. 213, gives a large number of 
references, but he includes some adult cases of pigmentation after 
urticaria which do not belong to true U. pigmentosa. 



URTICARIA PIGMENTOSA. l73 

in different parts of the body, nodules from the size of a hemp 
seed to a large bean, and extensive infiltrations, with the color 
varying from a brownish-red in the recent, up to pale or deep 
fawn in the older formation. When once the nodules are fully 
formed and have become yellow they may remain unchanged 
for a long time, even for years, though after friction or a scratch 
they usually redden and become more prominent; occasionally, 
also, bullae with clear contents form upon them, and dry up in a 
few days, leaving a thin crust upon the nodules. Other nodules 
may, after a variable time, shrink and become soft, wrinkled, 
and ultimately disappear, leaving brownish pigmentation, or, as 
in Hallopeau's case, white cicatrices. He has also noted cases 
with scarring due to vesiculo-pustules on the lesions. After a 
variable period, always several years, fresh nodules are no 
longer formed, and the old ones are gradually absorbed by the 
time puberty is reached, if not sooner. In Levinski's case,* 
however, fresh nodules were still making their appearance at 
eighteen years of age. In Morrow's it had lasted twenty-two 
years, and other cases also show its persistence into adult life. 

Itching, often severe, usually precedes and may accompany 
the formation of the nodules, and with this ordinary wheals ap- 
pear, and factitious urticaria is common, and should always be 
tried for; ecthyma may appear as another consequence of 
scratching. In some of these cases the wheals and the bullae 
preceded the nodules, but it is probable that the bullae do not 
form independently of wheals or nodules. 

Variations. — In non-pruritic cases all these secondary lesions 
are absent. The deep yellow xanthoma-like lesions may also 
be absent, the eruption consisting entirely of yellowish-red or 
brownish-red lesions. 

In the Macular form, while the general symptomatology is the 
same and wheals appear from time to time, the only permanent 
lesions are fawn-yellow pigmentary stains on the site of wheals 
and usually level with the skin, but occasionally slightly raised, 
permanently or temporarily. In one of my cases the stains 
were closely set over the whole of the trunk and limbs, the face 
alone almost escaping. After several years of treatment the 
wheals ceased to appear and most of the staining faded away. 

In the Nodular form the permanent lesions are all, or nearly 
*Virchow's Arckiv., Bd., 88, 1882. 



i 7 4 DISEASES OF THE SKIN. 

all, firm or yellow and xanthoma-like, as in my Atlas case. 
They usually begin as dullish red or copper-colored patches, 
which subsequently become yellow. The majority are from a 
pea to a bean in size, but may be larger from coalescence, and in 
Barr's case there were numerous plaques of great size.* 

Wallace Beatty f has recorded three cases of urticaria with 
pigmentation presenting several peculiarities. Two were 
brothers, set. twelve and fifteen; the other was a lady, set. twenty- 
three. They all had urticaria of the ordinary type, and one boy 
had also factitious urticaria. Besides the ordinary wheals, ex- 
tremely irritable red papules, from a quarter of an inch in 
diameter, appeared in crops, which in a few days flattened down 
and became brown spots of corresponding area, many of them 
with a white center; in the case of the boys the brown spots, 
which were rather larger than those of the lady, ultimately be- 
came quite white, smooth, foveated, or with radiating lines on 
the surface, and firm to the touch and level with the skin, but 
there was no atrophy of the skin structure, only of the pigment. 
The affection was very chronic and affected all regions of the 
body. Elliot's \ case was probably one of this kind. 

Etiology. — The majority of the cases have been boys (six out 
of eight of my cases). Nearly all have commenced before six 
months, and the majority under three months. The earliest 
age was one of my own cases, in which red patches were noticed 
when he was first washed, and white wheals came a day or two 
later; of later origin are Stelwagous case at eighteen months; 
a case of mine which began after chicken-pox § between five and 
six years; of Tenneson, aet. ten years (mast-cells found). 
Whether Liveing's, Mackenzie's, Pringle's, and some other cases 

* Vide case of xanthoma multiplex, Lancet, May 12, 1888, p. 923. Dr. 
Barr was kind enough to show me this case, which had some very large 
permanent yellow plaques. Factitious urticaria was also present, and I 
had no doubt of the case being an urticaria pigmentosa. See also case 
reported from Russia in Brit. Jour. Derm., vol. iii. (1891), p. 65, as 
xanthoma in a child. 

f Brit. Jour. Derm., May, 1891, p. 136. 

% Amer. Jour. Cut. and Gen.-Urin. Dis., vol. ix. (1891), p. 296. 

§ A. Woldert also records a case of a male child, set. three months, 
after varicella. Abs. Brit. Jour. Derm., vol. xii. (1900), p. 362; and Pick, 
in Kaposi's Festschrift, records a case following vaccination and com- 
mencing on the vaccinated arm as U. perstans. 



URTICARIA PIGMENTOSA. l75 

of adults with pigmentation and urticaria are examples of true 
U. pigmentosa is open to doubt, but in Elliot's case, where the 
eruption began in a man aet. twenty-eight, mast-cells were 
present in the lesions in great quantity, while in a case of Quin- 
quaud's, set. fifty-five, mast-cells were absent, and Lesser had an 
adult case in which there was no excess of mast-cells. The very 
early commencement of most cases suggests some congenital 
predisposition, but beyond this we cannot go. In one of my 
cases gastro-intestinal catarrh was a prominent cause of the 
activity of the disease. 

Pathology and Anatomy. — Since Unna's* observations in 1887 have 
been fully confirmed and are now generally accepted, those of his prede- 
cessors need not be discussed, though those of Thin, the Hoggans, and 
Colcott Fox may be specially mentioned. Unna says the epidermis is 
unaltered, except from the accumulation in the basal prickle layer of 
ordinary pigment, and some stretching and flattening. Immediately 
beneath the epidermis there is an enormous accumulation of mast-cells 
filling up the papillary layer, and the edema is limited to the papillary 
body. The deep part of the corium is almost unaffected. 

The accumulation of mast-cells, which are supposed by some to be 
derived from the blood- cells, by others from the connective tissue cells of 
the cutis, are now considered by most observers, except Doutrelepontand 
Neisser, to be pathognomonic of true U. pigmentosa, and would distin- 
guish it from the pigmentation following ordinary wheals, seen in a few 
adult cases, in which there are no mast-cells in excess. Slight differences 
from Unna's observations have been found by others, such as slight 
hemorrhages in Pick's and Fabry's cases. Brongersma, in Galloway's 
case, found the mast-cells throughout the whole corium and subcutaneous 
tissue in rows and columns, the cells being polygonal from pressure, 
except near the center of the lesions, where they are of the usual spindle 
shape. Further, Galloway and Brongersma found edema throughout 
the whole cutis. My own observations agree with these. 

Gilchrist examined from a case of U. pigmentosa a piece of normal 
skin, a four-minutes', an eight-minutes', and a twenty-minutes' wheal. 
He found in the normal skin more mast-cells throughout than would be 
found in the skin of a normal person, and there was progressive increase 
round the vessels and skin appendages in the wheals in proportion to 
their duration. Hence Brongersma infers that the mast-cells must be 
derived from the connective tissue, and that the pathogenetic factor is a 
congenital tendency for the connective tissue cells to develop into mast- 
cells, and the urticarial wheal, or angio-neurotic element, is a secondary 
phenomenon, possibly the result of a toxin derived from the degenerated 

* Unna's "Histology," p. 955, references to 1891. Gilchrist, Johns 
Hopkins Bulletin, vol. vii. (1896), p. 940; Brongersma, Brit. four. Derm., 
vol. xi. (1899), p. 177, with the most important references to date. 



176 



DISEASES OF THE SKIN. 



cells, and that the permanent lesions of U. pigmentosa are of the nature 
of tumors — a view practically that of Unna, who regards them as 
" stagnation tumors." * Even if it is true that the degeneration products 
act as toxins in the production of the urticarial element, that would not 
necessarily make it an entirely different disease. For it is fairly arguable 
that all urticarias are only angio-neuroses secondary to some toxin, and 
not only is their urticarial character evidenced by the consideration of 










*£* 




Fig. 11. — Section from border of a yellow plaque of several years' dura- 
tion, showing masses of mast-cells running for most part in lines, and 
situated below the papillary layer of the corium. X 1 in. Ross. 

the recorded cases as a whole, and not by aberrant cases like Fox's and 
my own first case, but most of the distinctive appearances of this eruption 
are seen as occasional features in ordinary urticaria. Thus, great per- 
sistence of the wheal is seen in U. perstans; bullae occur in U. bullosa; 
pigmentation follows ordinary wheals in many cases. Exudation into the 
papillae is seen in U. papulosa, and hemorrhage in U. haemorrhagica. 

* Unna uses this term in a special sense different from the ordinary 
meaning of " tumor," and applies it to any accumulation of cells, even 
flat plates, like those of keratosis palmae, or, as he calls it, keratoma. 



URTICARIA PIGMENTOSA. 1?7 

And the clinical and histological facts can best be reconciled by the theory 
of a congenital predisposition to the production of auto-toxins which act 
on the vaso-motor nerves, the toxins perhaps being derived from the 
accumulation of mast-cells. But what makes the mast-cells * accumulate ? 

Diagnosis. — The permanent buff-colored, wheal-like nodules 
generally associated with ordinary wheals, and always com- 
mencing in early infancy, are quite distinctive; but when the per- 

Fig. 12. — A portion of Fig. n highly magnified.— Mast-cells in rows. 
X | immersion. Powell and Lealand. 

manent lesions are distinctly yellow, without itching or any urti- 
carial symptoms, and the case has gone on for a very long time, 
it is liable to be mistaken for xanthoma tuberosum. A careful 
study of the lesions and of their mode of development, with their 
firmness to the touch and the early age of onset, will distinguish 
them, and if urticaria factitia can be produced strong confirma- 
tion would be afforded. Pigmentation following wheals, and 
without any permanent lesions, is met with at all ages. 

Prognosis. — The disease will probably get well ultimately by 
the time puberty is reached, if not before, but this is all that can 
be said of it for most cases, but in one of mine with yellow 
nodules, which began when three weeks old, the lesions under- 
went spontaneous involution before he was a year old, leaving 
cicatrices. 

Treatment. — Nothing hitherto tried has appeared to have any 
effect in removing the eruption, though much can be done to 
relieve the pruritus by local means, which are of the same kind 
as for ordinary urticaria. In one of my cases of the Sangster 
type with chronic intestinal catarrh and offensive motions, relief 
was always obtained if the bowels were put into order, espe- 

* Mast-cells (Ehrlich) are now regarded as coarsely granular basophile 
leukocytes corresponding with eosinophile leukocytes except in their 
staining capabilities (Green's " Pathology "). Some authors still regard 
them as transformed connective tissue cells. They are stained red by 
Unna's polychrome methyl-blue method. 

12 



178 DISEASES OF THE SKIN. 

daily by the use of salol and benzo-naphthol and other intesti- 
nal disinfectants, in three- to five-grain doses. After about five 
years' treatment, much of it spent in educating the mother as to 
the dietary, avoiding sweets and undigested starch, not only did 
the wheals cease to appear, but the greater part of the pigmen- 
tation faded. In another case, where there was no indication 
in the health to follow, small doses of Liq. Fowleri niij three 
times a day had a marked controlling influence in preventing 
fresh development, but only a few of the minor lesions dis- 
appeared. 

PRURIGO. 

Deriv. — Pnirire, to itch. 

Synonyms. — Fr., Strophulus prurigineux (Hardy), Scrofulide 
boutonneuse benigne (Bazin); Gcr., Juckblattern. 

■Definition. — A disease, characterized by the presence of con- 
stantly recurring, discrete, chronic inflammatory, white or pale 
red, slightly raised papules, most abundant on the extensor sur- 
faces, and accompanied by intolerable itching. 

There are two varieties of this disease — P. mitis (Willan) and 
P. ferox (Hebra),* the difference being one of intensity rather 
than kind. The latter has only been recognized since 1881 as 
occurring in this country, and even now extreme forms are rare. 
Other varieties have been made by some writers, by using the 
term prurigo in the same sense as pruritus. This leads to con- 
fusion, and should be avoided. Hutchinson's " Summer 
Prurigo " is described under Recurrent Summer Eruptions. 
Besnier would like to revive Willan's strophulus, lichen, and 
prurigo under prurigos, but this is to put the clock back, and 
the modern view is to restrict the term as above stated. 

Symptoms. — Individually, the papules are the color of the skin 

* Author's Atlas, Plate VII.; medium severity. Hebra's Atlas, Plate 
VII., Lief, iv.; extreme of thighs and knees. Mr. Morrant Baker read 
a paper on " Prurigo," at the International Congress of 1881, and showed 
some cases which the German authorities present acknowledged to be 
the true prurigo of Hebra. In 1855 White of Boston says that its 
frequency in Vienna was 1 in 45. It was a subject of discussion in the 
third International Congress on Dermatology, 1896. Vide articles by 
Besnier, J. C. White, etc. 



PRURIGO. i 79 

at first, to be felt, rather than seen: but as they get scratched 
they become more raised, convex, pale or even deep red, with a 
dark scabbed top (blood-crust) at the apex. Their size is from 
a hemp seed to a large pin's head, and they are never grouped. 
They are most abundant and highly developed upon the ex- 
tensor surfaces of the extremities, and in the order of intensity 
occur on the legs below the knee, the front and outer surfaces 
of the thighs, the forearms, the thorax back and front, the sacral 
region and buttocks, the lower part of the abdomen, the arms, 
and dorsum of the feet. 

A few papules only appear on the face,* whilst the flexures 
are almost always free, as are also the neck, palms, soles, and 
scalp. The hair is, however, dull, dry. and dusty-looking. The 
itching is most intense and the consequent scratching produces 
thickening and hardening of the skin, striated and diffuse pig- 
mentation, deepening of the natural furrows, while the lanugo 
hairs of the surface are broken off or torn out. and fine mealy 
scales are abundantly detached. When the disease shows no 
further symptoms than these, and the papules are moderate in 
number, or, as occasionally happens, limited to the lower ex- 
tremities, it constitutes the P. mitis of Willan ; but when it at- 
tains to the intensity of P. ferox. the papules and scales are 
more abundant and larger, the legs and forearms feel like very 
coarse brown paper, which is a characteristic symptom, the sub- 
cutaneous fat is atrophied, and secondary lesions are so in- 
variably present, though not without intermission, as to be 
essential parts of its symptomatology. 

These are (i) eczema, which may be so extensive as to cover 
the parts with crusts and mask the original disease, the flexures, 
however, being rarely involved; (2) urticarial wheals; (3) ecthy- 
matous sores; and (4) sympathetic enlargement of the femoral 
glands, often developing into large tuberous masses; while 
those in the axillae and above the elbows are also enlarged, but 
to a less extent. This gland-enlargement remains when the 
other eruptions are quiescent for a time, and may thus assist in 
the diagnosis. 

There is no special defect of health associated with prurigo, 

*•' Summer Prurigo," in which, in summer, the prurigo appearance is 
closely reproduced, is in most cases limited to the face, forearms, and 
hands. 



180 DISEASES OF THE SKIN. 

except what may be due to loss of sleep; but of course they are 
liable to the same diseases as other people. The face is generally 
clear and pale. 

Etiology. — It affects both sexes, but males twice as often as 
females, according to Ehlers; it is essentially, though not exclu- 
sively, a disease of the poor, want of food and bad hygiene being 
the most important factors; and, according to Hebra, it is aggra- 
vated by cold weather. This, however, is contrary to my ex- 
perience; some cases certainly come out worse every winter, but 
all my severe cases were better in winter, while, of the mild cases, 
some were worse in summer and some in winter. As regards 
age, it begins usually in the first year of life — in one of my cases 
it dated from one month old, but Ehlers speaks of a few days 
after birth. Hebra's dictum that it always began in infancy is 
given up. I have met with cases at various ages up to twelve, 
and many observers not only corroborate this, but extend it up 
to twenty-nine (Ehlers).* No doubt, however, cases beginning 
over six years old are exceptional. 

It probably begins as an urticaria papulosa or lichen urticatus, 
in favor of which there is a preponderance of testimony, but 
Besnier still holds that prurigo is not developed from urticaria, 
and in this Colcott Fox agrees. Comby, on the other hand, 
quotes cases in which the transition from urticaria to Hebra's 
prurigo apparently occurred. Few, if any, now accept Hebra's 
view that the papules are primary, for, as Besnier truly says, 
" the pruritus survives the papules; the papules never survive the 
pruritus." 

At the beginning of the second year, according to Riehl, small 
wheals appear together with the larger wheals, and it shows its 
predilection for the special regions already mentioned; but it is 
not until the end of the second to the fifth year that the disease 
is fully developed, the papules increasing in number more and 
more, while the larger wheals decrease. Thenceforth, unless 
vigorously and persistently treated at once, it persists through 
life, though with marked occasional remissions, either in warm 
weather or cold weather, according to the special idiosyncrasy. 
These are the only positive factors as to its etiology which are 

* Ehlers found that the extremes were from a few days to twenty-nine 
years. He analyzed 207 cases from Haslund's clinic. Ann. de Derm, et 
de Syph., vol. iii. (1092), p. 861. 



PRURIGO. 181 

established, but there are many to negative the various hy- 
potheses that have been put forward to explain it. 

Some pale, intensely itching papules, soon becoming scabbed- 
topped, sometimes appear in the later stages of Hodgkin's dis- 
ease, and constitute the " Pseudo-leukemic prurigo " of German 
authors. 

Pathology. — The real pathology of this disease is unknown. 
Hebra says the clinical facts are against its being a pure neu- 
rosis, and that the papules are always primary; but the evidence 
of the primary eruption being an urticaria is almost conclusive, 
and gains acceptance in most quarters, and would go far to 
prove that it was a neurosis to which all the eruptive phenomena 
were secondary. Ehlers regards antecedent urticaria as merely 
a coincidence, but on the other side cases like that of Hal- 
lopeau * and Barrie may be cited. 

Anatomy. — Anatomical examination f of the skin has been made by 
numerous observers, both ancient and modern, from Hebra and Kaposi 
downward. Only the more modern, such as those of Riehl, Kromeyer, 
Leloir and Tavernier, and Unna, need be mentioned. Unna examined 
eleven papules of prurigo gravis, and his results are those chiefly 
embodied here. He agrees with Riehl that every prurigo papule has an 
urticarial basis. There is always a spastic edema of the cutis and great 
increase in the number and size of the perithelia of the vessels, the latter 
being greatly thickened. In addition, he confirms Leloir and Tavernier, 
who found cavities formed by degenerated prickle cells, covered with 
thickened horny layers, so that the vesicle is invisible to the naked eye, 
even when, as a consequence of scratching, the cavity gets filled with 
leukocytes and becomes a pustule with its base on the papillae, its apex 
at the split horny layer, through which it is sometimes visible as a yellow 
point. Unna says that there were no staphylococci in the pus, but there 
were some other minute cocci, singly and in pairs. Unlike Leloir, he 
found no connection between the vesicles and the sweat pores. He also, 
like Auspitz, found the arrectores pili in spastic contraction, so that the 
hair in the center of most papules, if not torn out, is erected, and in 
addition he finds proliferative and exudative inflammatory changes and 
necrosis of the follicle, to which Caspary originally called attention. In 
brief, there are a series of epithelial changes with both growth and 
necrobiosis of the surface and follicles above a central severe cellular 
infiltration of the cutis; these changes originating in a chronic peri- 
vascular growth, and an acute spastic edema. In old-standing cases 
there are also secondary changes which prurigo shares with eczematous 

* Ann. de Derm, et de Syph., vol. iii. (1892), p. 520. 

f Unna's " Histology," p. 136, gives the most important references. 



1 82 DISEASES OF THE SKIN. 

dermatitis of long standing, when there is the condition described as 
" lichenification " present. 

Diagnosis. — The disease dating from infancy, with the pale 
red, scabbed-topped, itching papules on the extensor aspect of 
the limbs, the nutmeg-grater sensation they give to the touch, 
the excoriations, secondary eruptions, and enlarged glands, con- 
stitute a very characteristic group of symptoms. As it is the 
combination of the various lesions which makes up the diagnosis, 
error in well-marked cases can arise only by making an imper- 
fect examination. 

'The disease most liable to be mistaken for it is severe chronic 
eczema in a xcrodcrmatous subject, especially as both xeroderma 
and prurigo date from infancy, and have a harsh, dry skin; but 
there are neither characteristic papules nor the secondary 
lesions of prurigo in the eczema, which would probably affect the 
flexures, and all similarity would vanish upon removing it; 
moreover, there would be comparatively long intervals of free- 
dom from the eczematous condition. 

The knowledge of the possibility of confusion, and the exer- 
cise of ordinary care, will prevent error as regards pruritus 
cutancus from pediculi, acari, or other cause; the same may be 
said of chronic urticaria, eczema, and ecthyma; they, however, 
are not liable to be mistaken for prurigo, but, being complica- 
tions, may mask it when extensive, and be regarded as the pri- 
mary, instead of the secondary, lesions. 

Difficulties arise, however, in the first years of life in severe 
cases of urticaria papulosa, when it might be open to doubt as 
to whether it will go on to prurigo, a view which would be fav- 
ored in proportion to the severity and persistence. Cases which 
begin after infancy might also be open to doubt. They are 
usually of mild character, often with partial distribution, and the 
complications would be absent or slight, such as impetigo con- 
tagiosa and urticaria, the severity of the itching being out of 
proportion to the apparent mildness of the lesions. The per- 
sistence of the papules and the rebellious character of the erup- 
tion to treatment would be the chief guides. 

Prognosis. — This depends upon the age of the patient and the 
duration of the disease. It is curable in early life, occasionally 
also in adults; as a rule there are remissions, and the patient's 



PRURIGO. 183 

sufferings may be alleviated by treatment, by which the lesions 
are so much reduced that delusive hopes of a cure are enter- 
tained, but only to be disappointed. Much depends upon the 
persistence of the treatment which can be afforded to the patient, 
so that relapses can be promptly dealt with. The cases of the 
greatest severity (fifteen per cent., Ehlers) are perhaps incurable 
from the first. 

Treatment. — The indications are to relieve the itching, to re- 
move the eruptions, both primary and secondary, and to im- 
prove the general health. To fulfill the first two indications, 
external remedies must be chiefly relied upon, and applications 
which produce softening and removal of the uppermost layers 
of the cuticle are, according to Hebra, the most effectual; but 
internal remedies may afford some relief to the itching. Im- 
proved hygiene, especially a liberal dietary, cod-liver oil, and 
iron, are the most effectual means to restore and maintain the 
general health; but it is astonishing how much temporary 
benefit, both to the lesions and the comfort of the patient, is 
sometimes produced by merely keeping the patient in bed, and 
giving a liberal diet. 

I have found, also, that the tincture of cannabis indica, given 
internally, exercises a marked influence over the itching, miti- 
gating it considerably; it must, however, be given in full doses; 
e. g., for a child of eight or ten I begin with five minims, and in- 
crease it up to even thirty minims, three times a day, directly 
after meals, allowing an interval of a fortnight in its administra- 
tion about every six weeks. When taken in these large doses 
for a long period it may produce dullness of intellect and loss of 
memory, effects, however, which soon pass off when the drug is 
suspended. Blaschko says that antipyrin, beginning with two- 
grain doses, also gives great relief. Dobrowski has found that 
thyroid extract suppresses the eruption as long as it is taken, 
but does not cure. Any eczema or ecthyma that may be present 
having been first removed by the usual means, I have found the 
following course of treatment effectual for the alleviation of the 
remaining skin troubles: the daily use for half an hour of alka- 
line baths 1 ij to 1 iv sodae bicarb, to thirty gallons water at 
90 F., inunction of oil of cade 3 3 to 3 j of lard or vaselin or of 
naphthol ointment as below, twice a day; tincture of cannabis 
indica internally as first described, cod-liver oil and iron when 



1 84 DISEASES OF THE SKIN. 

indicated, and plenty of good food. I have also employed sul- 
phid of potassium baths with benefit. 

Massage, preferably with a lubricant like vaselin, has been 
found by Murray of Stockholm to give great relief to and even 
to abolish pruritus for a time, and thus to procure the subsidence 
of secondary eruptions. Hatschek of Vienna and others con- 
firm this. 

There are several modes of treatment recommended by the 
Vienna school, where they see a far larger number of cases than 
we meet with in England. 

The soap treatment of Hebra is very effectual, especially where 
there is great infiltration of the skin. A piece of flannel moist- 
ened with warm water is dipped into the spiritus saponatus alka- 
linus (Lotions, F. 5), or into the fluid glycerin soap, and the 
parts rubbed briskly for some minutes ; the latter is then washed 
off, and the body rubbed over with vaselin or other emollient. 
This process is to be repeated daily for a week. The skin should 
then be rubbed over with an emollient, and after an interval the 
treatment repeated. It is unsuitable for very young children, or 
where there are any sores or much eczema. 

The Sulphur Treatment. — This may be applied in various ways 
and combinations — sulphid of potassium baths or sulphur fumi- 
gations, sulphur and sulphur-sand soaps, or Hebra's sulphur 
ointment used as follows : Rub it well in all over, after the patient 
has had a bath; let him lie thus smeared, naked between 
blankets, and repeat the inunction night and morning for a week. 
The patient is then to get up, and in three days the epidermis 
begins to be shed, and he should then have another bath. After 
the course, slight cases appear quite well, severe ones much bet- 
ter. This plan is suitable for older patients who can give them- 
selves up entirely to treatment. 

Vlemingkxs solution of lime and sulphur (Parasiticides, F. 11), 
though not quite so effectual as the ointment process, can be 
employed without the patient giving up his occupation. It is 
suitable for cases with dry papules only; the patient, after a thor- 
ough washing with soap and water, should be well rubbed with 
the solution, then take a warm bath for an hour, and afterwards 
a cold shower-bath. My own form of nascent sulphur and sul- 
phurous acid treatment (F. 37) is a milder but efficient variant. 

The Tar Treatment. — The tar bath gives good results; common 



PRURIGO. 



'85 



tar or carbolic acid is painted on with a brush, and the patient 
immediately steps into a warm bath, and stays there for from 
three to six hours;* the process may be repeated until it pro- 
duces an intense burning sensation, or tar acne is produced. 
Carbolic or tar soaps or lotions, such as liquor carbonis 
detergens diluted, are also useful, or any of the above prepara- 
tions of tar made into an ointment, and, indeed, the inunction of 
any form of grease gives some relief. 

Naphthol p Treatment. — This is strongly recommended by 
Kaposi, as equally efficient and more pleasant than the other 
methods, and it is also curative for the eczema complications. 
A five per cent, ointment for adults, or a two per cent, for a 
child, is lightly rubbed in every night, and every second night 
the patient may be washed with naphthol sulphur soap. This 
treatment is continued until the prurigo manifestations disap- 
pear, and renewed whenever the disease returns. I can indorse 
Kaposi's recommendation. 

According to Tenneson, complete occlusion from the air for 
several days gives immediate relief from the incessant itching, 
which may last for days, weeks, or even months, in mild cases. 
India-rubber clothing is the most practical way of carrying out 
the plan, but confinement to bed is simpler and almost as good. 

Perchlorid of mercury baths are recommended by Woolmer. 

Which of the above methods should be chosen depends upon 
the severity of the disease and its complications, the age and 
occupation of the patient, and the time he can give up to treat- 
ment; e. g., for infants and young children, alkaline baths and 
one of the tarry ointments, with the administration of cod-liver 
oil, will probably be efficient. Bed, cannabis indica, and naph- 
thol ointment are my chief means of treatment. Indications for 
the use of the various methods have been given under each, but 
it must be borne in mind that whichever plan is selected must be 
carried out vigorously and perseveringly for the cure of the 
young children and the relief of the older patients. 

* In all cases the patient should be carefully watched, as faintness may 
ensue from such prolonged immersion. 



1 86 . DISEASES OF THE SKIN. 

ECZEMA. 

Deriv. — 'EuZsgo, to boil over. 

Synonyms. — Fr., Eczema; Ger., Eczem, nassende Flechte. 

Definition. — An acute or chronic catarrhal inflammation, at- 
tended with severe itching, burning, and great multiformity of 
lesions, viz., erythema, papules, vesicles, pustules, scales, scabs, 
etc., while a continuous discharge of serum or pus is generally 
present in some part of its course except in the mildest forms. 

Dermatologists differ so much as to what conditions should or 
should not be included under eczema, that it is necessary to state 
in limine what the term connotes in this section. First as to 
what is excluded. All forms of seborrheic dermatitis which are 
treated in a special section under Seborrheides. 2. Those 
forms of dermatitis due to strong irritants which excite in all 
persons exposed to them a violent inflammation, clinically and 
anatomically distinguishable from eczema. This subsides spon- 
taneously when the irritant is removed, or at all events the in- 
flammation is readily subdued by treatment. These are dis- 
cussed under Dermatitis. On the other hand, there are many 
substances which are not irritants at all to the majority of those 
exposed to them, but in certain predisposed persons produce a 
dermatitis indistinguishable from eczema, not only in the part 
to which it is applied, but which will spread beyond this, and 
even lead to a similar inflammation, often symmetrically dis- 
tributed in distant parts. These forms of dermatitis are in- 
cluded here on grounds which will be discussed under Etiology. 

Eczema is the most common of all eruptions, and constitutes 
at least a fourth of the cases of all kinds of cutaneous disease 
(Bulkley finds it one-third). It is most protean in its manifesta- 
tions, often extremely persistent, while it is frequently associ- 
ated with, and dependent upon, many other morbid conditions, 
both external and internal. It is impossible to give a single 
definite and at the same time complete picture of even acute 
eczema in all its phases, but all the variations are primarily 
referable to four kinds of elementary lesions, so that the erup- 
tion may be vesicular, pustular, papular, and erythematous, with 
more or less scaliness, primary squamous eczema being a sub- 



ECZEMA. 187 

variety 6f the erythematous form. These may be combined in 
various ways and degrees of development; and may further be 
modified by an increase or decrease in the intensity of the inflam- 
mation; by the difference in the position and anatomy of the 
part attacked; or by the inflammation attacking only a part in- 
stead of the whole structure of the skin, e. g., the hair follicle or 
sweat gland; and lastly, by secondary changes resulting from 
long-continued inflammation. 

Whilst these elementary lesions are readily recognizable in all 
acute stages, they are not always so in cases, subacute either at 
the commencement or in the decline of the attack, nor in some 
of the chronic forms, from secondary changes in the skin. 
These modifications will be pointed out in their appropriate 
places. 

The four primary forms have the following points in common : 
they are all acute in development, though of indefinite duration ; 
each may come upon any part of the body, but at the same time 
has its favorite seat, on which it most frequently occurs and is 
most highly developed. Whilst, on the one hand, only one form 
may be present, and running its own course, seem quite a dis- 
tinct disease from the others; on the other hand, vesicles, pus- 
tules, papules, and erythema may be present all together, more 
or less mixed up, or on separate parts of the body, so that there 
can be no doubt that they are merely different expressions of the 
same morbid process. 

Then again, instead of preserving their special characteristics, 
the erythematous and papular forms may develop into the vesic- 
ular, and this again into the pustular variety, or the process 
may stop short at any point. Thus, then, the division between 
these forms is not an absolute one, but is useful for description, 
and to gain a clear conception of a complex process. 

Eczema in all forms, when not due to a local cause, is roughly 
symmetrical, though one side is often worse than the other. 

E. Vesiculosum. This is a common,* and in one sense the 
most representative, form of the disease. It is seen best and 
most commonly where the skin is thin, i. c, on the flexor aspect 

* Unna, "On the Nature and Treatment of Eczema," Brit. Jour. 
Derm., vol. ii. (1890), p. 231, says it is the least frequent; but, excluding 
his seborrheic form, this is not my experience. 



1 88 DISEASES OF THE SKIN. 

of the limbs, especially the flexures, between the fingers, behind 
the ears, etc. It begins with burning and itching, soon followed 
by the appearance of diffuse or punctate erythema, on which 
minute, closely aggregated, clear vesicles develop, enlarge, per- 
haps coalesce, and soon rupture, either spontaneously, or from 
scratching, exuding a clear, plasmic fluid, which stains and 
stiffens linen; the part all this time being intensely red, hot, and 
itchy, and attended with more or less infiltration and swelling. 
The itching is relieved somewhat when the vesicles rupture, but 
the burning remains, these symptoms being always worse at 
night, and when fresh vesicles are forming. 

Unlike other vesicular diseases, the rupture does not termi- 
nate the active part of the process, but there is a continuous dis- 
charge, either from fresh vesicles, or more frequently from the 
site of the ruptured vesicles, and whenever it is irritated by 
scratching into an excoriated surface. It is this weeping stage 
that is most frequently seen, the vesicles having generally rup- 
tured before the patient applies for relief; or, as very frequently 
happens, the violent itching or burning induces corresponding 
rubbing or scratching, which denudes the surface sufficiently to 
allow of the escape of the fluid without actual vesicles being de- 
veloped, or, if the outpouring of fluid from the vessels is gradual, 
the epidermis may crack and ooze without the formation of 
vesicles. Where the part is not disturbed the discharge may 
dry up into yellowish gummy crusts, and on removal a moist 
surface is exposed, on which a new crust soon reforms. 

In a favorable case, after a few days the fluid ceases to exude, 
the redness diminishes, the denuded part skins over, and only 
some transitory redness is left; or the subsidence may be less 
complete, and, though the discharge ceases, there is still redness 
and thickening, and the part is covered with scales instead of 
crusts. This is E. squamosum, a condition which will be more 
particularly described presently; or, instead of the exudation 
diminishing, it may, with the hyperemia and other symptoms, be 
increased, and the condition passes on into E. rubrum. 

As a rule, however, none of these events takes place, and the 
discharge may continue, though there may be some improve- 
ment, but fresh vesicles are frequently forming, either at the 
border of the patch or elsewhere, and so the disease may cover 
a larger and larger area, until nearly the whole body surface is 



ECZEMA. 189 

involved. It is very rare, however, for eczema to be abso- 
lutely * universal, and I have met with few instances of it; but 
it is very common for it to be very extensive and fairly earn the 
title of general eczema; on the other hand, it is often quite strik- 
ing how the eruption limits itself to one locality, and, even when 
cured for a time, returns in a future attack at the same place. 

It is astonishing how little the general health is affected, ex- 
cept in the aged, even in the most extensive cases. Pain, ten- 
sion, and itching succeed each other with each fresh outbreak; 
the patient loses rest, is very sensitive to cold, and may experi- 
ence a transitory sense of chilliness with each crop of vesicles. 
but he seldom has febrile or other symptoms affecting the pulse, 
temperature, urine, or feces. 

E. Pustulosum.f Synonym. — Eczema impetiginodes. 

Here, instead of vesicles, there are pustules due to pus cocci, 
and they may arise directly, or the vesicles may become pustules, 
which will be larger than the vesicles. It is most frequent in 
children and in those who are cachectic from any cause, espe- 
cially the strumous, and is most common and typical on the 
scalp. It is often seen as a folliculitis elsewhere, and thus may 
be found on the beard and whiskers, pubes and axillae, or scat- 
tered over the thighs ; but there is less tendency to form patches 
than in the vesicular form, and the folliculitis is secondary, being 
left behind after the general inflammation of the whole skin 
structure has subsided. Below the elbow or knee, however, it 
is frequently seen covering almost the whole limb. It is at- 
tended, usually, with less irritation and less redness and swelling 
than the vesicular form, and when the pustules burst and dry up 

* Universal pityriasis rubra may, and often does, develop from eczema, 
but the eczematous characters are then merged into those of pityriasis 
rubra. 

f E. impetigo was the term used by many older writers — impetigo being 
a generic term for pustular inflammation. Besides this, other qualifying 
terms were used by Willan and his immediate followers, such as impetigo 
sparsa for small scattered patches, I. scabida when there was unusually 
thick crusting, 1. erysipelodes when the inflammation was deeper than 
usual. • Melitagra was used for the honey-like crusts sometimes seen in I. 
figurata. and crusta lactea and porrigo larvalis were used for crusts on the 
face, in infantile eczema. Doubtless I. contagiosa was mixed up with 
these very often. All these terms had better be forgotten. 



i 9 o DISEASES OF THE SKIN. 

they form dark brownish-greenish crusts,* which may cover a 
large suppurating surface. As the inflammation subsides the 
secretion is stopped, the crusts dry completely, and can be easily 
picked off, except in a hairy part. 

E. Papulosum. Synonym. — Lichen simplex, f 

This is a common and often very obstinate form. Originally 
it was thought to be a kind of lichen, on account of the papules, 
which are due to the inflammation, affecting only the hair fol- 
licles or small groups of papillse. The papules may be either 
discrete, scattered irregularly, or grouped and perhaps con- 
fluent; and their favorite seat is the extensor aspect of the limbs 
and the back. They are about the size of a pin's head, acumi- 
nate, of a bright, less frequently of a dull red color, and may 
remain as papules throughout their whole course (lichen 
simplex). Often, however, with a lens a tiny cap of fluid may 
be observed, and when the vesicles on the top of the papules 
were evident and numerous the lichen was said to be inflamed, 
and it was called lichen agrius. When the papules were grouped 
in oval or roundish patches, a form not uncommon on the ex- 
tensor aspect of the forearms and hands and on the calves, it 
was lichen circumscriptus.J In this variety the vesicles and 
papules often coalesce into a weeping patch, and then it looks 
like ordinary vesicular eczema in the discharging stage, except 
that it is in roundish or oval patches, more defined than those of 
eczema usually are, and situated on the extensor aspect of the 
limbs. All these names are now disused in the above described 
senses, though there are still some who regard lichen simplex 
as a separate disease, even though the vesicles and papules are 
so frequently associated. All the papular forms of eczema are 
troublesome, on account of their obstinacy to treatment, either 
from the same papules or vesiculo-papules remaining for a long 
time, or from their dying away and reviving again and again in 
the most capricious and persistent manner. While burning and 

* Author's Atlas, Plate VIII., Fig. 2. 

f Lichen simplex chronique of Vidal is a different condition, described 
tinder " Lichen." 

X " Lichen circonscrit" of French authors now is applied to the lichen 
simplex of Vidal. Lichen circumscriptus has also been applied to the 
totally different affection now called seborrhea papulosa corporis. 



ECZEMA. igl 

tingling are the usual features in the vesicular, itching of the 
most intense character is experienced in the papular form, and 
blood-crusted papules are the natural consequence. When the 
papules are closely aggregated, they may coalesce into a scaly 
patch, constituting a form of E. squamosum often seen upon the 
limbs. 

E. Erythematosum is seen in its most typical form .on the 
face; there it is attended with much heat and swelling, the 
edema sometimes completely closing the eyes. It begins in ill- 
defined erythematous patches at any part, and may rapidly cover 
the whole surface or remain patchy; the color is bright, or dull 
red, the surface is not glistening, but rough from a slight scali- 
ness, and there is no discharge; after a time the scales cease to 
form, the redness diminishes, and it gets gradually well. In 
other cases the inflammation is constantly varying in intensity, 
now apparently getting rapidly well, and a short time after 
breaking out again as bad as ever, and this may go on for weeks, 
months, or even years. In other cases, again, it begins to ooze, 
by splitting of the epidermis, or with formation of vesicles, and 
discharges like the vesicular variety. When occurring on ad- 
jacent surfaces, as on and under the breasts or about the geni- 
tals, a muciform discharge ensues, and it is called E. intertrigo. 
On the other hand, the thickening and scaliness may gradually 
increase, and it lapses into E. squamosum. In some cases, not 
very infrequent, it takes the form of round or oval patches 
(E. orbiculare), well defined at the borders, two or three 
inches in diameter, bilaterally, but not symmetrically, scattered 
over a considerable area. Some authors regard this form as of 
seborrheic origin. 

E. rubrum or Madidans may be developed from any of the 
above four varieties, though it is most frequently a sequence of 
the vesicular or pustular form. In it the inflammation is of a 
most intense character, and while, like the others, it may come 
anywhere, it is most frequently observed in elderly people on the 
legs, the whole of which may be involved. The surface is an 
intense bright or dusky red, entirely denuded of the upper layers 
of epithelium, weeps profusely, and discharges a clear or turbid, 
straw-yellow glairy fluid, which may dry into large yellowish or 



1 92 DISEASES OF THE SKIN. 

brown crusts. These cover a great part of the limb, like a piece 
of armor, and when the edges are raised can be easily detached 
from the copiously discharging surface beneath, from which 
blood also exudes with the slightest friction. The infiltration 
is considerable, and as cases often last for a long time, the in- 
duration is great, especially on the lower limbs, and in the 
flexures, where it often occurs, deep and painful fissures are 
frequent. 

There is a circumscribed variety which occurs, in my experi- 
ence, only in persons of a markedly scrofulous type. In this, 
Eczema rubrum scrofulosorum,* the patches are sharply de- 
fined, of round or gyrate outline, often by coalescence of con- 
siderable size, and situated on the lower part of the leg and foot. 
The surface is deep red, constantly discharges a sero-purulent 
secretion, and spreads slowly at the margin, and unless properly 
treated runs a very indolent course. The lesion is evidently due 
to microbic invasion, and the local treatment based on that view 
is the most successful. The usual constitutional treatment for 
scrofula is a valuable adjunct. 

E. Squamosum. While E. rubrum is the result of increased, 
E. squamosum is an indication of decreased intensity of the in- 
flammation, and a large proportion of cases begin and remain 
throughout their whole course as dry scaly patches. 

It also may arise from any of the four primary forms, but it 
is most frequently a sequel of E. erythematosum — indeed, 
Hebra used the term in that sense. It is, however, better to re- 
strict it to the subacute inflammations, whether primary or sec- 
ondary to one of the more acute forms, as it is produced when- 
ever the inflammation is of too low a grade to cause much 
exudation from the vessels, exciting instead hyperplasia of the 
rete cells. It occurs mainly as ill-defined irregular patches of 
variable size, in which there is redness, and when the patch is 
pinched up very marked thickening is felt; the red ground is 
more or less concealed by coarse or fine scales, which may be 
abundant or scanty, but easily detachable, and never adhere into 
crusts like those of psoriasis. As a rule, the patches are not so 
well defined as the eczema-form cases of seborrheic dermatitis, 
to which in other respects they may show marked resemblance. 
* Author's Atlas, Plate IX., Fig. 2. 



ECZEMA. 



93 



This form is often well exemplified on the neck and limbs. In 
the mildest form it is not uncommon on the face, chiefly in chil- 
dren, as ill-defined, slightly scaly patches, with little redness and 
no perceptible infiltration; this used to be called pityriasis 
simplex, and is often due to the irritation of soap; it is often 
associated with seborrhea. In the more severe forms it 
may be obstinate, the secondary thickening being difficult to 
remove. 

Acute and Chronic Eczema. These terms are used in dif- 
ferent senses. They may refer to the intensity of the inflamma- 
tion or to its duration. Eczema may run a short course with a 
high grade of inflammation, and then no one would dispute its 
right to be called " acute," but more frequently the course is a 
long one, consisting of a succession of acute attacks, or rather 
exacerbations, with but trifling secondary changes. For all 
practical purposes such cases are still acute, and require the 
treatment for an acute inflammation, but lasting for months are 
often called " chronic." In other cases again secondary changes 
occur as the result of long-continued inflammation, and become 
the most important element for the treatment; and though liable 
to acute exacerbations, the inflammation, as a whole, is less in- 
tense. Such cases are clearly entitled to be called " chronic." 

These secondary changes are, first, induration and thickening 
of the tissues: when the induration is the main symptom it has 
been called " E. sclerosum " ; then the hardness is almost 
board-like, and the surface scaly. It is seen most frequently 
and in its highest development on the legs. 

In some instances, where the thickening is also very great, a 
condition indistinguishable from elephantiasis arabum is pro- 
duced (E. spargosiforme). The tissues may be enormously 
hypertrophied, producing deep folds at the bends of the limbs, 
and sometimes indolent ulcers, and the limb is so cumbersome 
and useless that the patient is glad to be relieved of it by ampu- 
tation. Of course these are only the worst cases, and there are 
all gradations up to this, which may be mitigated by treatment 
even when they cannot be cured. In some cases hypertrophy 
of the papillae takes place, and a diffuse warty condition ensues ; 
it may be covered with an epidermic crust, or an evil-smelling 
discharge may exude from between the papillae; this is 
13 



1 94 DISEASES OF THE SKIN. 

" E. verrucosum " and " E. papillomatosum." These condi- 
tions may be combined in various proportions. 

Ulceration and edema are also occasional events, chiefly in 
connection with varicose veins. The extreme conditions are 
very exceptional, but they are not always indicative of a very 
long duration. They are almost confined to the legs below the 
knee, as are also the modifications induced by varicose veins, 
such as orange, brown, or blackish discolorations from subcu- 
taneous hemorrhages, and a livid hue of the patches, which 
sometimes simulate those of lichen planus. 

It is common to see qualifying terms for eczema, simply in- 
dicative of their locality, such as " eczema capitis," " eczema 
genitalium," " eczema palmare," etc. They are for the most 
part simply convenient to express briefly the limitation of 
the eruption, but at the same time the clinical features are often 
modified by the locality. Some of these modifications will be 
specially referred to. In eczema capitis et faciei the inflam- 
mation is much more liable to take on a pustular form, and the 
inflammatory products are mixed with the sebaceous secretion, 
become entangled in the hair, and form thick crusts of a dirty 
greenish-black hue, often with a foul odor. " Eczema faciei," 
probably from its external position, is often very obstinate, 
being the last part to get well; and showing a great tendency 
to recur, even without apparent provocation. " Eczema 
genitalium," eczema of the scrotum or vulva, begins as an E. 
erythematosum, and is often limited, in the case of the scrotum, 
to the lateral surface, on account of the natural heat and moist- 
ure aggravating the inflammation. The pruritus is so intoler- 
able that the patients lacerate themselves severely in seeking 
momentary relief by scratching, and much secondary thickening 
of the parts may thus be induced; also, owing to the moisture, 
scales and crusts do not adhere to any extent. 

E. Palmare. Eczema of the palms and soles is so modified by 
the thickened epidermis of those parts that it is often called 
psoriasis palmae. Vesicles are seldom formed, but there is 
congestion and great irregular thickening of the epidermis, and 
the constant motion and loss of flexibility leads to its splitting 
and forming fissures, chiefly in the lines of motion, which pene- 
trate to the corium, and every movement is most painful, so that 



ECZEMA. I95 

the patient is quite disabled from manual employment. This is 
the E. rimosum of McCall Anderson. The inflammation may 
be limited to the center of the palm; but usually it starts at the 
root of the thumb or wrist, and gets into the palm subsequently. 
Longitudinal fissures often occur at the tips of the fingers and 
thumbs. The nails may also be involved; they become dis- 
colored, of a dirtyish-yellow hue, are pitted, furrowed, thick- 
ened or thinned, split both vertically and into lamellae, and pro- 
duce great disfigurement. When (chiefly in hyperidrosis palmae) 
vesicles do occur on the sides of the fingers or palms, where 
the skin is thick, they often do not rupture spontaneously, but 
remain as small, transparent, dark spots, not raised above the 
level of the skin, and compared to boiled sago grains, or where 
the inflammation is very intense the original vesicles may 
coalesce into irregular bullae. Between the fingers and on the 
back of the hands, where the skin is thin, they rupture readily 
enough. The well-known " chaps " are of similar pathology, 
except that there is not an eczema present, and that they are the 
consequence of local irritants, especially insufficient drying after 
being in water; but badly made soap, very hard water, handling 
acids, etc., are other common causes. 

Children. — It is in what may be called " infantile eczema," 
that is, as it is seen under five years of age, that the most 
marked differences are noticeable. The chief of these is its 
much greater tendency to be pustular, a tendency which it 
shares with most kinds of inflammation in childhood. Another 
point is its being more easily excited by local irritation, and also 
reflexly, through irritation of the alimentary canal. The head 
and face, especially behind the ears and on the cheeks, are most 
frequently attacked, and when other parts are involved it is gen- 
erally by spreading downwards from the head, though there are 
often intervening intervals of healthy skin. 

In strumous children, and occasionally in others, subcu- 
taneous abscesses are frequent, especially in the occipital region, 
and they may be very extensive. They often form rapidly and 
insidiously, with very little constitutional disturbance. En- 
larged occipital and cervical glands are also common. In 
analyzing over 300 cases of eczema, under thirteen years of age, 
from the Children's Hospital at Shadwell, I found that under 
five years old there were 81 per cent, on the head and face, against 



196 DISEASES OF THE SKIN. 

19 per cent, in all other positions; while from five to twelve the 
proportion was only 63 per cent. Where the eczema was in 
more than one region, both were counted. Adding 340 cases 
from Shadwell to 353 from University College Hospital, making 
693 cases in all, there were 423 males to 268 females; 575 cases 
were under five years, while 176 were from five to thirteen; and 
of these 575, 327 were under two years; and of these again, 322 
were under one year. The totals made about an equal number 
up to six months and below twelve months, and six years; but 
at University the number between six and twelve months pre- 
dominated, while at Shadwell there were more up to six months. 
With this exception the number at both places agrees most 
curiously, and shows that one-third of all cases in children be- 
gin in the first year of life ; and since many of the older cases had 
persisted since infancy, this is an under- rather than an over- 
estimate. In the second and third year the numbers are nearly 
equal — 94 and 88; but after that the disease steadily declines in 
frequency to the sixth year, and from that age remains nearly 
the same up to thirteen. 

According to Unna, the " eczema capitis et faciei " of children 
occurs in three forms — the seborrheic, the nervous, and the 
tuberculous. The tuberculous is the form seen chiefly on the 
face, or in association with conjunctivitis and rhinitis or otor- 
rhea in the strumous children of the poor, and in my opinion is 
nothing more than a dermatitis excited by contagious pus — a 
form, indeed, of impetigo contagiosa. If the supply of con- 
tagious pus be stopped by suitable treatment of the conjuncti- 
vitis and rhinitis, the dermatitis is readily cured by the applica- 
tion of diluted ammonio-chlorid of mercury ointment, or similar 
antiseptic application. 

Unna found that some of these cases improved under 
tuberculin injections, and thought it confirmed his opinion as to 
the tuberculous nature of the affection; but tuberculin may 
modify various kinds of unstable tissue, and I have seen warts 
disappear after one or two injections given for lupus. 

The nervous form is, he says, due to reflex irritation chiefly 
from dentition, and is characterized by great itching and tend- 
ency to recur. It commences on previously healthy skins on 
the cheeks and forehead, and radial surface of the back of the 
hands and wrists, often spreading up the forearms to the lower 



ECZEMA. 197 

third of the arms. With this I agree, except that dentition plays 
a much less important role than he states, irritation of the ali- 
mentary canal from unsuitable food being the most frequent 
factor in the majority of cases, for the disease often starts long 
before teeth need be thought of. According to my observation, 
beyond a slight exacerbation of a pre-existing eczema just be- 
fore the eruption of a tooth, the process of dentition is as harm- 
less as a priori one would expect a natural process to be. 

In the seborrheic form the skin was not previously healthy, 
a progressive seborrhea of the scalp having been present, per- 
haps from a few weeks after birth. After acquiring a moist 
character,^ it attacks the ears, forehead, cheeks, eyebrows, but 
not the rest of the orbits, and extends to the shoulders and 
upper part of the arms in usually dry, fatty foci; the fatty char- 
acter is always preserved even when the surface is moist. The 
eruption is much less irritable than the nervous form, but more 
than the tuberculous, and has a constant tendency to generalize 
on the genitals, back, and lower limbs. 

While this account is clinically a true description of some 
cases, I do not think there is such a sharp line of demarcation 
to be drawn between the nervous and the seborrheic forms, 
either as regards pathology, course, or treatment, as Unna 
does; indeed, he admits that it is not always possible to make the 
distinction, especially if not seen at the early stage, and his 
statements as regard treatment are only of limited application, 
viz., that ichthyol in the gelatin zinc paste must be prescribed 
for the nervous form, while it is useless in the seborrheic form, 
in which sulphur or resorcin ointments are the applications 
indicated. 

The Elderly. — Chronic squamous patches, with great thicken- 
ing, are frequent about the lower part of the legs. This arises 
partly from varicose veins, partly from the frequency of develop- 
ment of the gouty diathesis, the ankles being a favorite position 
for gouty eczema. 

In very old people also eczema is one of the signs of decay 
or of defective elimination, and when acute, may leave freckle- 
like pigmentation behind it. Often it is very extensive, but mild 
in degree, being only slightly rough and red, with tendency to 
superficial splitting of the epidermis, and general paroxysmal 
itching out of proportion to the degree of inflammation. A con- 



i 9 8 DISEASES OF THE SKIN. 

dition intermediate between psoriasis and eczema occurs some- 
times on the hands of elderly women. The edges of the eruption 
are well denned, and the patches are dry, scaly, and intensely red 
and itching; but when there has been any eruption elsewhere, it 
has been more distinctly eczematous, and is therefore placed 
here. 

Eczematous inflammation is much modified in appearance 
when it is limited to any one of the appendages of the skin. 

Seborrheic eczema is described under the seborrheides. 

Sweat eczema may be seen in various forms. An inflamma- 
tion of the sweat glands is seen in milaria rubra and lichen 
tropicus, and is not usually classed with eczema. 

Many persons who suffer from habitual hyperidrosis are liable 
every summer to a vesicular eruption, which starts along the 
sides of the fingers as minute vesicles with slight inflammation 
round, and may be limited to those positions, or may, if more 
severe, extend with increased inflammation to the palms and 
other parts of the hand. 

A general eruption,* chiefly on the trunk and inner aspect of 
the limbs, sometimes follows a chill, whilst in an overheated or 
actually sweating condition. The eruption, then, consists of 
irregular groups of acuminate or rounded pin's-head papules, 
which, in parts, coalesce into irregular slightly scaly patches, so 
that, as a whole, the surface is more or less thickly covered with 
irregular scaly patches, with single and irregularly grouped 
papules interspersed. There is moderate itching, and if the 
patient is not subjected to alternations of temperature it is fairly 
amenable to treatment. 

Hair follicular eczema is represented by the various papular 
forms of eczema already described as occurring on the extensor 
aspect of the limbs. Under the title of Eczema folliculorum 
Morris describes what he considers a special form characterized 
as follows: 

" Each inflamed follicle stands out on the skin as an angry- 
looking red pimple (? papule); the capillaries- round are con- 

*This form of eruption is depicted in Plate XI. of my Atlas. In the 
text it is suggested that it may be seborrheic, but I have since had strong 
clinical grounds for considering it to be a sweat eruption. 



ECZEMA. 199 

gested, and soon the skin is involved in the process. In this 
way red patches dotted with inflamed follicles are formed, which 
tend to spread by the extension of the inflammation from follicle 
to follicle. As a patch spreads at the edge it usually undergoes 
resolution in the center, desquamation takes place, and the red- 
ness fades into a yellowish stain. The itching is often most in- 
tense. The patches are generally multiple, and are scattered 
about the body, especially on the extensor surfaces of the arms 
and legs. The predilection for the extensor surfaces of the 
limbs is a distinctive feature, and the affection is obstinate, and 
recurrence is almost the rule. It is closely allied to sycosis, 
and there can be little doubt that it is of parasitic origin." 

Nervous Eczema. Although disturbances of the nervous 
system often lead to an outbreak of eczema (vide Etiology and 
Pathology), I do not believe that there is anything special in its 
external characters which would enable it to be recognized apart 
from the history and other evidence of the nervous origin, and 
there is not, therefore, sufficient warrant for the creation of a 
special variety. 

Etiology. — Men * and women are alike subject to eczema from 
the first to the last week of existence. At the same time it is 
more common in the infantile period, and in the decades from 
twenty to thirty, and thirty to forty. Heredity, although often 
put forward, has but slight claims to be considered as a cause, 
heyond the fact that some skins are more vulnerable than others 
to external and internal noxious influences, and the parents will 
probably transmit a similar skin to their offspring. 

The causes of eczema are external and internal. Some au- 
thors exclude all cases in which a local irritant has been the ex- 
citing cause. Thus Morris says, " Lesions due to such causes 
may be exactly like those of genuine eczema, but there is this 
fundamental difference: they appear in response to a visible 
cause, and begin to disappear when that cause ceases to 
operate." f As a general statement this is only true for the 

* Hebra gives the frequency of males to females as one to two, but this 
is probably due to special peculiarities in his clinic. For interesting 
statistics on eczema see Bulkley's monograph, chapter ii. In children, as 
I have shown, males predominate as five to three. 

f Discussion on Eczema at Brit. Med. Assoc, in 1898, Brit. Jour. Derin. 
vol. x. (1898), p. 350. 



200 DISEASES OF THE SKIN. 

strong irritants which will excite violent dermatitis in any skin 
exposed sufficiently long to their influence. Rhus toxicoden- 
dron, tartar emetic, croton oil, turpentine, etc., may be cited as 
examples. As a rule this dermatitis is readily recognizable as 
due to an irritant having characters very different from ordinary 
eczema. (Vide article Dermatitis.) 

The weaker irritants require a predisposition on the part of 
the individual, either permanent, from the skin being especially 
sensitive, or temporary, from some want of general vigor from 
various causes, the same irritant being ineffective when the in- 
dividual's vital powers are at their best. 

In a very large proportion of such cases the eruption does not 
" begin to disappear when the cause ceases to operate," if that 
means when the irritant has been removed. On the contrary, 
the inflammation not only spreads beyond the part to which the 
irritant was applied, but an eruption, often symmetrical, may 
start up in quite different parts of the body, and present the same 
appearance and run the same erratic course of the " true eczema 
which arises without obvious cause." I believe, therefore, that 
it is more logical and practical not to draw such arbitrary dis- 
tinctions, and to consider all cases as eczema which correspond 
in their morphology and general behavior irrespective of the 
cause being tangible or intangible, external or internal. 

The possible external causes are almost as numerous as the 
number of agents that will irritate the skin ; it will thus be only 
necessary to give examples of different classes of irritants, as a 
complete list of them would be almost interminable. To some 
of these eczemas names have been most unnecessarily given, 
the irritant differing, but the eczema being much the same, ex- 
cept where the intensity of the irritation varies; E. solare, E. 
mercuriale, and E. sulphure are examples of these superfluous 
designations. 

All irritants may be divided into chemical, thermal, and 
mechanical. The ehemical irritants include a large number that 
are used medicinally, such as the whole class of counter- 
irritants, sulphur and mercurial inunction, dilute acids, dyes, 
soaps that contain an excess of alkali, etc. The thermal irri- 
tants are the direct rays of the sun (E. solare) and artificial heat, 
which often produces eczema in those exposed to it, such as 
stokers, blacksmiths, and cooks. 



ECZEMA. 20 1 

Cold has a strong influence, and eczema is more common and 
severe in winter than in summer. It is especially injurious 
when combined with wet, and when the parts exposed are al- 
lowed to dry spontaneously, as exemplified in washerwomen and 
barmaids. The nature of the fluid, the strong soda of the one 
and the beer of the other, often plays an important part, but the 
excessive use of water in the form of baths, as in hydropathy, 
mineral spring cures, etc., may also produce a sweat dermatitis 
or a veritable eczema. 

Of cold, per se, the winter eczema of the ichthyotic may be 
specially mentioned, though it is by no means limited to them. 

Mechanical irritants, such as handling dry powders, scratching 
in pruritic eruptions — parasitic or otherwise — the friction of 
articles of clothing, pressure, etc. 

Many of these might be classed as " trade eczemas," and are 
at first limited for the most part to the parts exposed to the 
irritant, though it may spread from that as a starting-point, and 
moreover the inflammation does not always subside at once 
after the removal of the irritation. Their nature was formerly 
misunderstood, and so we meet with such expressions as 
"baker's, grocer's, and biicklayer's itch." The bichromate of 
potash used by French polishers so much nowadays sometimes 
produces a recognizably "irritant dermatitis"; in others, one 
indistinguishable from eczema. In most of these " trade 
eczemas " a predisposition is generally required, as many mem- 
bers in the same trade escape evil consequences altogether. 

Morbid secretions, such as diabetic urine, decomposing sweat, 
and various discharges from mucous membranes, vagina, nose, 
etc., may produce eczema either by acting as irritants or by the 
presence of pathogenic micro-organisms in them. Xasal dis- 
charges almost always contain pus cocci, which will probably 
set up their special lesions. 

Predisposing Causes. — These are very important, sometimes 
indicating the most effectual line of treatment. They may be in 
the skin itself, congenital or acquired, or in the general organ- 
ism, the so-called constitutional conditions. The skin itself 
may be anatomically defective, as in ichythosis and its milder 
form of xerodermia, the last being especially important, as it is 
easily overlooked. The dry degenerative changes of the skin 
in old age also favor the development of eczema, which extends 



202 DISEASES OF THE SKIN. 

widely, and is often very rebellious to treatment when it once 
gets a footing. 

T. Fox thought that the eczematous skin in all persons was 
irritable and dry; that dryness favors the occurrence of eczema 
is well exemplified in the case of ichthyotic patients, but I would 
hesitate to say that the skin excretions are deficient in the 
majority of eczematous patients; indeed, eczema is common in 
association with hyperidrosis, and probably both in this and 
seborrhea, the excessive secretion, like the scratching in 
severely pruritic diseases, favors parasitic invasion. 

There is one local condition that greatly favors the occurrence 
of eczema in the neighborhood, e. g., varicose veins, whether of 
the leg or rectum. Any part being chronically congested is 
halfway towards inflammation; just as in emphysema the train 
is always laid for bronchitis, so it is with varicose veins and 
eczema — a slight local irritation or vital depression, and the in- 
flammation is lighted up. 

Besides the visible defects of the skin there are invisible de- 
fects which make some persons' skin more vulnerable to eczema 
than others, but there is little satisfaction to be gained from the 
theory of the older French authors * who laid great stress upon 
what they called the dartrous diathesis, to which they refer 
eczema and several other cutaneous diseases, but these views 
now meet with but little acceptance in or out of France, and 
need not be discussed at any length. 

With regard to the internal causes, there has been an immense 
amount of hypothesis, often reposing on a very slender founda- 
tion. 

The eczema patient is seldom in a state of well-being at the 
time of the supervention of eczema. Instead of the clear, ruddy 
complexion, so often seen in psoriasis, a heavy expression, and 
pasty, or even earthy complexion, is the rule; the patient gen- 
erally complains of something, sometimes only of " being out 
of sorts," has lost energy, or is no longer up to his work. One 
of the most common factors is an exhausted nervous system 
(the neurasthenia of American writers), whether from worry, 
anxiety, overwork, either of mind or body, or from disease; in- 

*See Bazin in "Affect. Cutan. Arthrit. et Dartreuses," 2d ed., p. 47 
et seq. (Paris, 1868), and Hutchinson's "Lectures on Rare Diseases of the 
Skin." 



ECZEMA. 



203 



deed, eczema is almost like a parasite in the way it seizes upon 
and nourishes on the weak or vitally depressed, independently 
of the cause of the depression. 

Foremost among all internal disorders I would place derange- 
ment of the alimentary canal; the complex condition known as 
dyspepsia is very frequently present, and the bowels are very 
often disordered, either from constipation or from diarrhea or 
deficient bile. This may, however, be simply a concomitant, an 
acute eczema being often associated with pale motions, furred 
tongue, and urine loaded with lithates, and as the two often 
come on simultaneously, it is reasonable to suppose that there 
is a catarrh both of the alimentary canal and of the skin. Al- 
though only an hypothesis, it is highly probable that these con- 
ditions favor the development and absorption of toxins in and 
from the intestinal canal, which directly or indirectly excite the 
eczema. 

Where lithemia, as described by Murchison, is frequently 
present, such as in patients of the gouty diathesis, there is little 
doubt that there is a causative relationship between it and 
eczema. Whilst fully admitting that the gouty state strongly 
predisposes to eczema, I believe that there is much exaggera- 
tion of the frequency of gouty eczema, and that when a middle- 
aged eczema patient is told that he is suffering from suppressed 
gout or perverted gout, it is too often only a refuge for the dis- 
tressed diagnostician. Of course, if the view that all dyspepsia 
is an inchoate gouty state be accepted, my objection vanishes. 
How these various disorders produce the eczema is open to dif- 
ference of opinion; Wilson and others included them under 
assimilative debility, Tilbury Fox regarded them as instances of 
retained excreta, which in the blood act as irritants to the 
tissues. 

Put into the language of modern pathology, this would 
nearly coincide with the absorption of intestinal toxins into the 
blood, to which allusion has already been made. They may act 
directly or reflexly upon the nerve centers, and produce dilata- 
tion of the capillaries of the region affected. In infantile eczema 
irritation and consequent catarrh of the alimentary canal are 
even more common as a cause of eczema than in older people. 
The imperfect feeding of which infants are too often the victims 
is a fertile cause of the skin-troubles, and is much more often 



204 DISEASES OF THE SKIN. 

the fons et origo mail than teething, which, for infantile diseases, 
often takes the place of " suppressed gout " of the middle-aged; 
at the same time I cannot go so far as Hebra, who denies that 
it has anything to do with the matter. I think it often aggra- 
vates a pre-existing eczema, and there are other grounds for be- 
lieving that irritation of the fifth nerve will produce eczema, such 
as Cavafy's * case, in which eczema followed neuralgia of the 
second branch of the fifth, and was limited to its area of distri- 
bution. In an infant of nine months what appeared to be a 
scaly eczema came out suddenly after an attack of sickness and 
diarrhea and formed streaks one-eighth of an inch above and 
broadening out to half an inch at the wrist in the distribution of 
the circumflex and radial cutaneous branches. It had not al- 
tered two months after its first appearance. \ Such cases as 
these are rare. 

The distribution is more frequently in areas governed by com- 
mon vaso-motor centers than in those of single nerves. The 
most familiar example is that of the bust and arms, but I have 
seen it persistently limited to the malar eminences in several 
successive attacks. 

Rickets also is often put forward as a cause of eczema; I be- 
lieve it is so indirectly in some cases, especially as catarrh of 
the gastro-intestinal tract is seldom absent in rickets, while the 
child's powers are much depressed; how far they are dependent 
upon each other, or upon a common cause, is open to discussion. 
With regard to the " strumous state," it is an outcome of low- 
ered vitality, and as such is a predisposing cause of eczema; it 
exercises a modifying influence also upon the kind of inflamma- 
tion, favoring suppuration, so that it is a predisposing cause of 
pustular eczema. The special form of eczema in scrofulous pa- 
tients has already been described (p. 192). 

Another class of cases in which eczema appears to be a reflex 
neurosis is in uterine disorders, which even Hebra admits as an 

* Brit. Med. Joicr., July 24, 1S80; also Montfort and Mirallie's case of 
eczema in the domain of an ulnar nerve with neuritis and simultaneous 
cure of the nerve and skin inflammation, Annates de Derm., etc., vol. viii. 
(1897), p. 1264. A case of eczema in the course of the small sciatic and 
short saphenous nerves is recorded by Shearer, Gtas. Med. Jour., Feb- 
ruary. 1885, with photograph, but I am not quite sure from the descrip- 
tion that it was really an eczema. 

f Private case book G., p. 96. 



ECZEMA. 205 

important factor. He and others have known women in whom 
eczema of the hands was always present in pregnancy, and con- 
stituted the earliest reliable sign. The presence of uterine 
tumors, the climacteric period, the termination of lactation, con- 
gestion and subinvolution of the uterus, etc., are further ex- 
amples of uterine derangements as causes of eczema, which is 
also not infrequent in chlorotic girls. Reflex neurotic eczema 
from disease of other viscera is probable, but seldom demon- 
strable. 

Bulkley considers eczema and asthma to be so frequently 
associated or alternating that he regards asthma, in many cases, 
as a sort of eczema of the pulmonary mucous membranes. I 
cannot say that I have found the association frequently, but that 
a chill will excite a simultaneous inflammation of the skin and 
mucous membranes is readily intelligible. 

Bulkley * is also very strong on disturbances of the nervous 
system producing what he calls " neurotic eczema," which 
" affects both sexes and at all ages from the cradle to the 
grave." He considers dentition and puberty and nerve strain in 
childhood and adult life as important etiological nerve factors. 
Leloir and others have adduced striking cases in which nerve 
shocks or prolonged nervous strain of anxiety or worry have 
been the immediate antecedents of eczema, often very widely 
spread, and all dermatologists can confirm this from their own 
experience. How it produces eczema is not so clear. To admit 
the facts observed in these cases, but to say that the disease is 
neurotic dermatitis, and not true eczema, is only juggling with 
words and begging the question. 

Renal Disease. Liveing considers glycosuria and slight albu- 
minuria to be common in chronic eczema of people past middle 
age. Granular kidney and renal inadequacy I have certainly 
found in a fair number, but sugar in my experience is rare ; how- 
ever, the following case is an example : A man set. sixty, who had 
been subject to eczema, but was in perfect health at the time 
when he bathed in the sea on a cold day, was unwell all the rest 
of the day, and on the following morning had spasmodic asthma 
and bronchitis, and in the evening eczema broke out all over 

* Bulkley, "Neurotic Eczema," Jour. Amer. Med. Assoc, April 10, 
1898, with many references. 



206 DISEASES OF THE SKIN. 

the head and face. His motions were very pale, and he had a 
small quantity of sugar in the urine, without polyuria, but there 
was no evidence of gout. In a previous attack of general 
eczema this man had had white motions for some time. 

I have also seen it in association with marked uremic symp- 
toms. Bruhns * cites several cases to prove the converse, viz., 
that eczema may produce acute nephritis. 

When an eczema has once been excited it does not subside 
as soon as the cause is removed, and the disease will go on in- 
definitely unless judiciously and perseveringly treated. It is no 
uncommon history to find a child in his teens who has had 
eczema more or less from early infancy, and in whom no defect 
in health to account for it can be discovered. 

In adults also we meet with cases where, after correcting 
every defect discoverable, and every function appears to be duly 
performed, yet the eczema persists. Often the disease appears 
to be subsiding under local and other treatment, when the end 
of the free interval arises, and all one's labor is undone in a 
single night. That such cases are frequently dependent on a 
nervous defect, the results of a treatment to be presently dis- 
cussed strongly corroborate. Hebra placed " faulty innerva- 
tion," without suggesting its nature, in the highest position as a 
cause of eczema; this I should indorse, and suggest that the 
chief factor is a reflex irritation of the nervous centers, produc- 
ing a dilatation of the capillaries in different regions of the skin, 
possibly through an inhibitory influence over the vaso-motor 
center. In some cases this irritation is from a distant organ, 
like the intestinal canal or uterus; in others it is from the skin 
itself. All these internal causes Unna disposes of by saying 
that their presence makes the skin a better nutritive basis for 
the hypothetical parasite of eczema, but this makes it equally de- 
sirable to remove them if possible. 

Pathology. — Eczema is a catarrhal inflammation of the skin, 
analogous to that of mucous membranes. So far all are agreed, 
but as to the pathogenetic factor or factors the diversity of 
opinion is as great as ever. The principal theories are the 
nervous, the parasitic, and the toxic. 

That, when not due to a local irritant, it is a tropho-neurosis, 
either central or peripheral, has been advocated by Hebra, Til- 
* Bruhns, Berlin, klin. Wochenschrift, 1895, p. 606. 



ECZEMA. 207 

bury Fox, Schwimmer, Leloir, Bulkley, etc., and Marcacci * in 
a fatal case of universal eczema found changes in the sympa- 
thetic. That the nervous system plays an important part in the 
production of eczema has already been shown under Etiology, 
but whether it is primary or secondary is open to dispute. If 
the latter, it might be an important or even necessary factor 
without invalidating other primary pathogenetic theories. 

Unna holds that eczema is a parasitic disease due to the 
morococcus, as he calls an organism consisting of clusters of 
cocci which he has found in the epidermis; and he explains the 
dermal inflammation set up by this epidermal parasite by in- 
voking an irritating toxin derived from the morococcal activity. 
Unna claims to have produced eczema from morococcus 
cultures, but, according to Torok, it was not a true eczema, but 
an impetigo. This morococcus has also been found in the 
vesicles of scabies, in the scales of psoriasis, etc., and it becomes 
a question whether its widespread existence does not argue more 
in favor of its banality than of its pathogenic importance. Ex- 
perimental proof of a toxin from it is wanting. 

Leredde is a strong advocate of parasitism in eczema, but im- 
poses reserves in accepting the morococcus as the agent. He 
thinks that the similarity of effect from such a multiplicity of 
causes postulates a parasite, but admits that it is inoperative in 
a normal skin. According to him, local irritants, the invasion 
of the acarus scabiei, scratching, etc., are only opening doors 
from the outside to the parasite, and favoring its deeper inva- 
sion; gastric fermentations, altered secretions, gouty conditions, 
etc., are only favoring influences from within. This is con- 
venient at all events, for this parasitic theory is not inconsistent 
with all the other hypothetic factors having a share in the pro- 
duction of the eczema, only reserving the leading role for itself, 
although it is powerless without other factors. The success of 
antiseptic local treatment is adduced as a proof of this 
hypothesis. 

Whilst fully admitting the importance of antisepticism in 
eczema, and indeed in all inflammations of the skin where the 
epidermis is disturbed, it may be explained by the secondary in- 
vasion of an inflamed surface, either by organisms from without 
or by previously present organisms which are harmless in a nor- 
* Giornale italiano delle Malattie ven. e d. ftelle, June number, 1878. 



208 DISEASES OF THE SKIN. 

mal skin. Such, we know, are staphylococcus aureus and its 
congeners, and streptococcus, and all modern authors are agreed 
that there is secondary invasion by one or more of these organ- 
isms, and that their presence has to be reckoned with, both as 
modifying the clinical aspect and in the indications for local 
treatment. 

At the International Medical Congress in Paris, in 1900, the 
parasitism of eczema was one of the subjects of discussion, and 
those who took part in it were almost unanimously against 
Unna's view. They all agreed that the fluid from the unrup- 
tured primary vesicles was amicrobic, and they were all equally 
unanimously in favor of secondary infection, chiefly by the 
staphylococcus aureus and the streptococcus. According to 
Sabouraud, the staphylococcus transforms the eczema vesicle 
into a pustule, and after proliferating in the vesicle it can then 
excite in the neighborhood directly, i. e., without primary 
eczema vesicles, numerous miliary pustules. When the strep- 
tococcus invades an eczema it produces, between the primary 
vesicles, superficial phlyctenular below the horny layers which 
may coalesce and produce extensive superficial erosions with 
exudation which dries into their yellowish crusts. In unin- 
fected but ruptured eczema vesicles the corresponding depres- 
sions are discrete and exude in droplets, but when streptococcal 
infection occurs the whole surface oozes uniformly. It is to be 
hoped that these precise differences will be confirmed by other 
observers. Sabouraud also states that the " morococcus " be- 
longs to the staphylococcus group. The flask bacillus and a 
small special bacillus are concerned in the seborrheic forms of 
dermatitis. 

The hypothesis of parasites being the sole cause of eczema 
(the so-called seborrheic eczema excepted) creates, in my opin- 
ion, more difficulties than it solves; for amongst many other ob- 
jections, we must suppose that the parasite is absorbed into the 
circulation and germinates as in the exanthemata, or how else 
are we to account for the frequent sudden outbreak of eczema 
with a symmetrical distribution, in definite vaso-motor regions, 
such as those of the xerodermia pigmentosa area, the acne 
rosacea area, etc.; sometimes supervening on a dermatitis from 
a local irritant? Toxin absorption from the original source 
of inflammation is the only other plausible hypothesis. 



ECZEMA. 209 

My own view is this : that, while a limited number of cases of 
local dermatitis indistinguishable from eczemas are parasitic, 
in most the dermatitis, however caused, only opens the door to 
parasites whose presence keeps up local irritation, so that their 
destruction is an important step in the restoration of the skin 
ad integrum. Seborrheic dermatitis is on a different footing, 
and I admit its local and parasitic nature unreservedly. That 
eczematous inflammation becomes pustular from cocci I have 
already stated, and that partial or complete cure results from 
their destruction. It will thus be seen that in practice there is 
agreement, while in theory there are differences. 

That toxins may and do cause eczema in many cases is more 
than probable, and their most frequent source is the alimentary 
canal (auto-toxins), i. c, such a theory accounts for most of the 
clinical symptoms, and they may act by damaging the nutrition 
of the tissues directly or indirectly from the toxic effect on the 
nerves of the affected area. At the same time it is as difficult 
to afford definite proof of this theory as of any other. Be- 
lievers in the parasitic theory would say that toxins of local 
manufacture, i. e., at the site of the dermatitis, play an impor- 
tant part, and indeed, for the morococcus such a theory is 
essential to make it viable as a pathogenic agent. 

There remains the possibility that eczema is due to different 
pathogenetic agents, but that they all act through the nervous 
system. 

To show the difficulties of each theory, the following example 
may be taken. A man given to alcoholic excess sustained a 
contusion of the left leg, to which he applied a weak solution of 
arnica. A smart dermatitis was excited on the leg, which 
looked like a diffuse, slightly discharging, and scaly eczema, 
and nothing in its appearance suggested a local irritant. Three 
days after the leg inflamed, the orbits swelled up considerably, 
and the skin there was bright red. The back of the forearms 
and hands presented fine acuminate papules on their extensor 
aspect, all quite symmetrical. 

On the parasitic theory it must be supposed that the irritant 
brought into pathogenic activity an organism already in the 
skin, and that this was multiplied and absorbed into the 
systemic circulation, whence it was carried to the symmetric- 
ally inflamed parts, or that at the part irritated the parasite 
14 



2io DISEASES OF THE SKIN. 

(? morococcus) produced a toxin which acted on the common 
vaso-motor center for the face and back of the forearms and 
hands. 

On the nervous theory it would be sufficient to suppose that 
a local irritant produced, by reflex action on the vaso-motor 
center above mentioned, the symmetrical inflammation de- 
scribed. On the auto-toxin theory the local irritant may have 
acted by leading to either the production or absorption of a 
toxin from the alimentary canal by a reflex nerve action, just 
as chills of the surface appear to produce similar results in 
some cases. 

In all these theories the predisposition or vulnerability from 
alcoholic excess must be taken into account, weakening the re- 
sistance of the tissues of skin or nerve, or producing gastro- 
intestinal catarrh, and fermentative changes favoring toxin pro- 
duction, according to the theoretic view taken. This example 
shows how each theory requires a plentiful amount of supposi- 
tion to get over its deficiencies, and also that at present we are 
far from a perfect and provable working theory. 

Anatomy. — This has been investigated by Simon, Hebra, Wedl, Rind- 
fleisch, Kaposi, Neumann, Biesiadecki, Robinson of New York, Leloir and 
Vidal, Unna, and myself. In acute eczema the changes are chiefly and 
primarily in the papillary layer, afterwards in the epidermis, and, if of 
sufficient duration, the deep portion of the corium may be involved. 

In papular eczema the inflammation is in circumscribed portions of the 
skin, and Robinson says is primarily confined to the follicles, especially 
the hair follicles, while in the other forms it is more or less diffuse. 
Unna makes practically no distinction between eczema and seborrheic 
dermatitis, and lays great stress on the changes in the epidermic cells, 
which are swollen by imbibition of fluid (inflammatory edema), and their 
normal functions otherwise interfered with. Thus the upper cells of the 
prickle layer do not undergo normal keratinization {parakeratosis), but 
remain moist in their interior, adhere into masses, and form scales in the 
subacute and chronic forms. In the more acute forms the upper layers 
are lifted off by the fluid beneath before many changes have occurred. 
The deeper prickle cells proliferate as well as swell {acanthosis), with 
multiplication and diffusion of mitoses. When there is enough fluid to 
form vesicles the prickle cells themselves are elongated and almost 
thread-like, where the vesicles are large, and the vesicles are formed in 
the upper part of the rete or just beneath the horny layer, by the serum 
from the vessels making its way between the cells, and raising up the 
horny layer. Besides the serum they contain loose prickle cells, and 
some of these swell from imbibition, rupture, and impart the gummy 
character to the vesicular contents (Robinson). In the papular and 



ECZEMA. 



211 



squamous forms the fluid exudation is slight; in the pustule it is abun- 
dant, and there is more cell emigration and proliferation, and therefore 
more infiltration of the corium and epidermis. 

Spindle cells make their way into the rete, and form a close network 
between the cells, the meshes of which are filled with the prickle cells, 
this network extending sometimes right up to the horny layer. 

The papillae are swollen in all directions, the vessels dilated, the con- 
nective tissue corpuscles increased in size and number, and the fibrous 
bundles swollen by imbibition and compressed, these changes giving 
strong evidence of serous exudation. 

Chronic Eczema Rubrum. — Robinson says the previously described 
changes in the corium are here more marked and deeper, and the lowest 
layers of the prickle cells are so altered that the lower border is badly 
defined from the corium, while the upper border is very irregular, from 
the changes in the horny layer, which is broken up into fragments con- 
sisting of nucleated cells adhering together. In chronic eczema squa- 
mosum there is proliferation and desquamation of the horny layer, while 
the deep part of the prickle layer is less altered, the corium and papillae 
are infiltrated with round cells, the vessels are dilated, and, in short, 
there are all the usual changes of a less active inflammation. 

The longer the duration of the process the more marked are the 
secondary changes, as exemplified in Figs, n and 12, representing E. 
palmare. The papillae are so much larger; the cell infiltration of the 
corium is more marked and goes deeper, Neumann and myself having 
found it even between the fat cells; he also found, not only the 
blood, but even the lymph-vessel loops elongated and dilated at the 
end. This enlargement of the papillae may go to a papillomatous extent, 
as before described in the clinical history; of this Robinson * gives a 
figure. When the lymphatic flow is impeded the elephantiasic condition 
is induced. On the other hand, Rindfleisch f has described, in some 
cases, great development of connective tissue, obliteration of vessels, 
and flattening of papillae. 

Diagnosis. — The diagnosis of eczema may be very easy or very 

difficult. It is easy when any one of the four primary forms is 
in a typical condition; or given the presence, or the distinct 
history of the presence, of a continuous discharge which stains 
and stiffens linen, whether serous or purulent, and the diag- 
nosis is made; for although there are a large number of erup- 
tions in which there are vesicles or pustules, they either dry 
up without rupturing, or, with the exception of impetigo con- 
tagiosa, do so as soon as their contents have been evacuated. 
On the other hand, the absence of discharge does not neces- 

* Robinson, p. 318. 

f Rindfleisch, " Path. Histology," Syd. Soc. Trans., vol. i. p. 349. 



212 



DISEASES OF THE SKIN. 




Fig. 13. 



Chronic Eczema from the 
Center of the Palm, x 
50. 
^ Fig. 13. — Superficial por- 
tion. 

a. Horny layer greatly 
thickened. 

b. Commencing vesicle. 

c. Round cell effusion 
into papilla. 

d. Enormously thickened 
""& prickle cell layer. The in- 
ter-papillary portions are 
very much elongated, pro- 
ducing corresponding en- 
largement of the papillae as 
at c, 

e. Dilated papillary ves- 
sels. 

f. Vesicle in the rete, in 
the course of a sweat duct. 

g. Sweat duct with round 
cell infiltration in and about 
it, throughout its course. 
In other parts the cell effu- 
sion is almost limited to the 
papillary layer. 




Fig. 14. — Deep portion cor- 
responding with Fig. 13. 
X 50. 

a. Continuation of sweat 
duct g in Fig. 13. 
bb. Sweat coil. 

cc. Abundant cell effu- 
sion in and around sweat 
coil. 



2»\ d. Fat with scanty cell 
effusion round the fat cells. 



ECZEMA. 213 

sarily imply the absence of eczema, for, like pleurisy, it may 
be with or without free effusion of serum. 

The vesicular form of eczema may be mistaken for scabies, 
herpes, and, when universal and weeping, for pemphigus folia- 
ceus; the pustular form, for impetigo contagiosa, tinea favosa 
of the scalp, sycosis barbae, and pustular syphilis of the scalp; 
the papular, for lichen acuminatus, papular urticaria, and papu- 
lar syphilids; the erythematous, for E. simplex and erysipelas; 
E. rubrum of the legs may also be mistaken for erysipelas; E. 
squamosum, for psoriasis and tinea circinata, and when on the 
palm, for the palmar syphilid. 

The diagnosis of the eczemaform seborrheide from eczema is 
given with the Seborrheides. 

Scabies v. Eczema. — These two diseases very closely resemble 
each other, and often give rise to great difficulty in diagnosis; 
and this is not surprising, since nearly all the lesions of scabies 
are individually of an eczematous character. 

Both itch much at night and both have vesicles, pustules, 
crusts, and scales. Where there are well-marked burrows 
from which an acarus can be picked out, or where there is evi- 
dence of contagion, there is of course no difficulty, but in an 
ill-marked case, especially when thrown off one's guard by the 
patient being obviously a clean person, or of the well-to-do 
classes, mistakes often arise. 

While the individual lesions of the two diseases, with the ex- 
ception of the acarian burrows, resemble each other, the gen- 
eral picture is very different, and if the rule of seeing the whole 
of the eruption were more generally followed, as it can be in 
males, mistakes would seldom occur. The general picture is 
especially useful where the burrows have not been developed; 
or where they have been destroyed or obscured by vigorous 
scratching; or from the nature of the employment, as in brick- 
layers, washerwomen, etc., the two points which afford most 
assistance are the positions and scattered character of the erup- 
tion. Scabies particularly affects the hands, especially between 
the fingers (an eczema position also), the flexure of the wrists, 
the axillae, the pubic region, especially the penis, and inner sides 
of the thighs in adults, while in infants the buttocks, feet, and 
hands are the favorable positions. If an eruption is scattered 
irregularly in any of these positions, it is of itself a strong pre- 



2i4 DISEASES OF THE SKIN. 

sumption in favor of scabies. Eczema also comes in these 
situations, but the lesions are always more or less grouped or 
patchy. A pustular eruption on the hands or feet of an infant 
is nine times out of ten due to scabies. 

Where the evidence for either is finely balanced, the effect 
of the treatment for scabies will decide the matter in a week. 

Pustular Syphilids of the scalp are often mistaken for pustular 
eczema. There is here superficial ulceration; and the loss of 
substance, either past or present (and scars should always be 
looked for), is decisive. The crusts may require to be removed 
before a diagnosis can be made, and this is always the safest 
course to pursue. The offensive odor of the pustular syphilid 
should excite suspicion, and further, the lesions are generally 
more circumscribed than those of eczema. 

Coccogenic Sycosis Barbcu bears a close resemblance to the 
later stage of eczema of the beard and whiskers. At the com- 
mencement, in eczema, there is inflammation, and perhaps 
vesicles, between the hairs, and the eruption nearly always ex- 
tends to the neighboring hairless situations; but as time goes 
on this may get well before the hairy part, and the eczema 
clearing up between the hairs, there is only a pustular follic- 
ulitis left, hardly distinguishable from sycosis. At a later 
stage the two conditions are identical, the whole skin being in- 
filtrated, of a deep red color, with crops of follicular pustules 
from time to time, and no doubt directly dependent on pus 
cocci. The treatment is also identical. Often, however, the 
eczema inflammation can be shown to be more superficial at 
first. On extracting the hairs some of them will be found to 
be infiltrated at the root, only a short distance down, while in 
sycosis the whole root-sheath is always swollen. 

Tinea Favosa of the scalp is likely to be mistaken for eczema, 
only when its possible existence is forgotten for the moment. 
The crusts are a more decided yellow, and often powdery ; some 
at least will be cup-shaped, and there may be atrophic scarring. 
If there is still doubt, the microscope would be decisive as to 
the presence of a fungus, though culture might be necessary to 
prove the exact nature of it. 

Herpes Zoster will seldom give much trouble; the definite 
arrangement of the patches in the course of a nerve will be 
quite sufficient; also the vesicles being much larger, except at 



ECZEMA. 



215 



the commencement, and the way in which they dry up without 
discharging, or at least without continuous discharge, consti- 
tute distinguishing features. This last symptom is a distinction 
between eczema and the other forms of herpes, viz., H. facialis 
and genitalis, which are more like eczema than zoster is, the 
vesicles of H. genitalis being very small. Their position, the 
circumstances under which they occur, and their short course, 
will be sufficient to prevent error. 

Pemphigus Foliaccus is very like a general weeping eczema; 
the diagnosis is given under Pemphigus. 

Impetigo Contagiosa, when due to pediculi capitis, its most 
common cause, is very like pustular eczema of the scalp. The 
localization is an important point; the eruption always predomi- 
nates in the occipital region; at the most, a few isolated scabbed 
spots exist in the other parts of the head; eczema is scarcely 
ever limited in this way, even in isolated spots; nits would also 
be discoverable, and the effect of treatment would be conclu- 
sive; impetigo contagiosa is curable in a week or two, while 
eczema nearly always takes longer. When impetigo con- 
tagiosa is on the face, the fact that there are always isolated 
lesions away from the main patch is sufficient. 

Lichen Acuminatus and Lichen Planus. — See those diseases. 

Papular Urticaria. — Eczema lesions are not infrequently 
mixed up with those of urticaria. In the papular form of urti- 
caria the lesions are never grouped, as in eczema; they are 
rather larger, not so hyperemic, and at least, the history of 
wheals is obtainable. When the scab-topped papules are 
chiefly distributed on the loins of a child, wheals should be al- 
ways inquired for. 

Large Follicular Syphilid v. Eczema Papillosum. — This syphilid 
always occurs in the early part of the secondary period, — that 
is, within about six months of infection, — and other syphilitic 
lesions are nearly always present. In the large follicular 
syphilid the papules are in groups of three to seven, which is 
very characteristic; they are also larger, a browner red, and do 
not itch. 

Erythema Simplex is not easily mistaken for eczema. The 
eruption is not in the least scaly, seldom itches, there is no in- 
flammatory edema, and all the other characters of eczema are 
wanting. 



216 DISEASES OF THE SKIN. 

Erysipelas v. E. Erythcmatosum. — When the face is affected 
the latter is often mistaken for erysipelas on account of the red- 
ness and edema, but there are no constitutional symptoms as in 
erysipelas; it does not begin at a special part like the orbit, its 
borders are never defined, it is usually bilateral, the surface is 
rough from the first, while in erysipelas it is shining, smooth, 
and tender, and desquamation only appears after the departure 
of the inflammation. In E. rubrum of the legs there is always 
profuse weeping, and the chronic course of the eruption ought 
to prevent mistakes. 

Psoriasis v. Eczema. — It is only when eczema is in dry, scaly, 
circumscribed patches, or when psoriasis is unusually hypc-r- 
emic, that mistakes are liable to occur. The diagnosis is given 
under Psoriasis. 

Tinea Circinata. — No mistake can occur when the tinea is 
present in its typical form of discrete circles made up of 
papules with a clear center; but when there is a uniformly scaly 
patch, irregular in outline, it may be impossible, except with the 
microscope, to distinguish between therm Often, however, 
there is ringworm in the scalp, or a more typical patch else- 
where, or a history of contagion to help out the diagnosis. 
Moreover, eczema is generally symmetrical to some extent, 
and the border less defined. A sharply defined border to a soli- 
tary scaly patch should excite suspicion of its not being eczema. 

Prognosis. — Eczema more frequently runs a chronic than an 
acute course, and, if left to itself, may persist indefinitely. It 
is always amenable to a persevering, judicious treatment, 
though when there are extensive secondary changes these may 
not always be removable. 

The elements for prognosis to be considered are: how far 
the eczema depends on some removable or irremovable defect 
in the general health, or other condition, e. g., varicose veins; 
the form of the disease; the mode of progress; the history of 
previous attacks, if any; the duration and intensity of the in- 
flammation; the position of the eruption; and the amount and 
character of the secondary changes. 

Thus, a gouty eczema in an old person, or where elimination 
is defective, as in granular kidney, is extremely likely to recur, 
or where there is a chronic cause of worry or anxiety, or other 
points in the external conditions are bad, the prognosis is un- 



ECZEMA. 



217 



favorable for the removal of the eruption. Papular is usually 
more obstinate than acute vesicular eczema. When every few 
days an outbreak occurs without apparent cause, when the 
eruption is of long standing, and elephantiasis, papillary hyper- 
trophy, or great induration has set in, or when it is on the 
scrotum, hairy parts of the face, or palms, the prognosis is 
more or less unfavorable, at least for a time, though there are 
few indeed which do not yield at last. In general eczema a few 
cases go on to pityriasis rubra, when the prognosis will be the 
same as for that disease. 

Treatment. — The treatment of eczema is very important, and 
its mastery will give the key to the treatment of three-fourths 
of the inflammatory diseases of the skin. The first point to 
investigate in all cases is the cause of the eczema; e. g., if it 
is limited to the hands, a local cause, especially such as would 
be connected with the occupation of the patient, would natu- 
rally suggest itself. Failing this, investigation should be made 
into the general health, the habits, and surroundings of the 
patient, and persevering attempts made to remove, modify, or 
neutralize any injurious influences, the great aim being to re- 
move or guard against depressing conditions and all sources of 
irritation, whether internal or external. With regard to these 
points, it is impossible to do more than give a few hints as to 
the lines on which to proceed, and which are likely to be bene- 
ficial in the majority of cases. There are no specifics for 
eczema, and as regards general treatment, the soundest prac- 
titioner for disease in all forms will be the most successful. In 
all cases the condition of the alimentary canal must meet with 
our first attention. Of the derangements there, constipation 
is the most common and most injurious, and success can 
scarcely be hoped for unless that is overcome; when chronic, 
but slight, the compound sulphur lozenges, or if obstinate, the 
aloes, nux vomica, and belladonna pill (Pills, F. 1) taken for a 
long period, are most useful, coupled with all the well-known 
rules for meeting that condition. As temporary adjuncts, the 
compound liquorice powder, or the liquid extract of cascara 
sagrada, may be given, while the aperient mineral waters, such 
as Carlsbad, Hunyadi Janos, iEsculap, Apenta, Friedrichshall, 
Piillna, etc., are often required two or three times a week; these 
waters are especially useful where there is passive congestion 



2 i8 DISEASES OF THE SKIN. 

of the liver. For infants, equal parts of the infusion of gen- 
tian and senna, a dram to be taken three times a day, to which, 
in obstinate cases, two or three drops of tincture of belladonna 
and tincture of podophyllin may be added, is a good formula, 
but it is disagreeable for a child to take. Liquid extract of cas- 
cara Tr\ij to rr|v, tincture of belladonna flliij, and compound in- 
fusion of orange 5ij, is better. Where there is dyspepsia, alka- 
lies and bitters, bicarbonate of soda for the majority and of 
potash for the gouty, is the usual treatment required. Bis- 
muth is useful with pyrosis or irritable tongue, and a small dose 
of strychnia or tincture of nux vomica in flatulent or atonic 
dyspepia. 

In children, in whom catarrh of the bowels is so common, 
sodae bicarb, gr. 5, sp. chloroform, Try, aquae anethi dil. 3j, for a 
child a year old, answers well in many cases where the motions 
are loose, offensive, and slimy, and frequently a grain of hy- 
drarg. c. cret. three times a week may supplement the mixture. 
Of course these are only given as examples of treatment for 
the common run of cases. For most patients the diet should 
be carefully regulated; food in which sugar is a feature and all 
fermentable articles of diet should be prohibited, sugar should 
be taken in very moderate quantities or not at all, especially 
with hot fluids, highly seasoned and made dishes avoided, and 
a dietary laid down, plain and nutritious, but with sufficient 
variety not to pall upon the appetite. Salt meats are only 
contra-indicated because, as a rule, they are difficult of diges- 
tion and less nutritious, weight for weight, than fresh meat. 
The salt itself is not injurious in moderate quantity. 

Alcohol must always be taken sparingly, as, except in very 
moderate quantities, it dilates the vessels of the skin, and 
therefore increases the blood in the too congested skin, and 
aggravates the itching; beer and the stronger wines are seldom 
admissible; sound clarets, hocks, and plain spirits freely 
diluted are the least objectionable, but in a large number of 
cases alcohol is better avoided altogether. In gouty cases the 
regimen and medicinal treatment for that condition must be 
adopted, taking care to insure a reduction of the amount of 
nitrogenous food on the one hand, and active exercise and 
means for promoting increased oxidation on the other. A 
course of alkalies, with saline aperients occasionally, is what is 



ECZEMA. 219 

usually indicated; but colchicum need only be given when there 
is high pulse tension and other indications of a gouty outbreak. 
For the want of tone and general debility, so often exhibited 
by eczema patients, the mineral acids and nux vomica, or 
quinine, or where there is anemia, iron, with plenty of outdoor 
exercise, short of fatigue, are the measures generally de- 
manded, and cod-liver oil is often highly beneficial. 

In children, especially if rickety or strumous, if the bowels 
and diet have been regulated, iron, such as the syrup of the 
iodid, the ammonio-citrate, or Parrish's food, with cod-liver oil 
and general hygiene, are the means best suited to combat such 
conditions. In all obstinate cases in adults the urine should 
be examined for albumin, sugar, and an excess of lithates or 
phosphates; indeed, it should be done as a matter of routine. 
In short, until every function is duly performed and the pa- 
tient's health has attained to the highest point of which his 
organization and circumstances render him capable, the prac- 
titioner should not rest satisfied. 

Speaking generally, in an acute case seen early, saline 
aperients are good treatment at first, and later on tonics suited 
to the patient's special conditions; while in cases of long stand- 
ing diuretics take a high place in relieving the skin troubles. 

But there are cases in which no particular departure from 
health can be discovered, or where such departure has been 
rectified, and yet the eczema remains uncured, owing to fresh 
attacks at short intervals; and then it is usual to try empirical 
remedies.. Arsenic has a high reputation in this connection; 
indeed, it is but too common a practice to resort to it when- 
ever there is the least hitch in the progress of the case, but in 
my experience it is a most disappointing drug in eczema. I 
do not doubt that a certain number of cases get well under 
arsenic, when it is combined with local treatment, but whether 
as post or propter hoc, I am not prepared to say; but it has nearly 
always failed in the only cases in which I have wanted its assist- 
ance, viz., those in which, what I venture to call the rational 
treatment has previously been unsuccessful, probably not 
more than three per cent, in all cases. 

Hutchinson and Malcolm Morris strongly advocate vinum 
antim. tart, in small doses, about T(\y three times a day. It is 
an old treatment revived, and I have certainlv found it service- 



220 DISEASES OF THE SKIN. 

able, but in a more limited number of cases than they appear to 
have done. It acts most favorably in acute cases, in a fairly 
robust individual; but if given to a debilitated subject, or in an 
otherwise unsuitable case, it will not only aggravate the eczema 
already present, but will excite it in fresh places. This I have 
seen several times, and regard it, therefore, as a drug powerful 
for good or evil, and consequently to be used only in carefully 
selected cases. Hutchinson, however, uses it freely at all ages, 
and claims signal success for it in a large proportion of cases. 
It appears to suit a good many cases of infantile eczema in 
drop doses three times a day. 

Another drug which I have found beneficial in uncomplicated 
cases, where there is no irritation of the alimentary canal or 
urinary organs, is spirit of turpentine. In many obstinate 
cases it has acted most satisfactorily, even when no local treat- 
ment has been employed. There is rather a prejudice against 
it, on account of its irritating effect in some cases on the 
urinary passages; but if given with proper precautions such 
irritation will be rarely seen, and will never be very great. It 
should be made into an emulsion with mucilage, and given 
three times a day, after meals. The dose at first should not 
exceed ten minims, and the last dose should be taken not later 
than 6 p. m., as discomfort on micturition in the morning some- 
times follows a late dose. The quantity of urine passed is often 
diminished at first, with copious deposit of lithates; therefore 
diluents, such as barley water, should be drunk freely, not less 
than a quart a day. This is very important, and the medicine 
should not be commenced until the barley water is ready. Un- 
less the patient is very intolerant, which is not often the case, 
the dose may be increased by five minims at a time up to twenty 
or thirty minims, and but few complain seriously of the taste, 
which can be masked by various flavoring agents, notably 
essence of lemon. 

But there are a few cases where the Pharmacopeia has been 
ransacked in vain, for every few days exacerbations set in, and 
undo over and over again the good effect of the local treatment. 
In such cases I endeavored to get at the vaso-motor centers of 
the part by applying counter-irritation over them. This proved 
more successful than I had expected, and the result was too 
immediate to doubt the connection between cause and effect. 



ECZEMA. 221 

In the upper half of the body it was used to the nape of the 
neck; in the lower, over the lumbar enlargement, **. e., the last 
dorsal and first lumbar vertebrae. Sometimes dry heat, in 
others a strip of mustard leaf, was used, or the liquor epispas- 
ticus was painted on. The application should be made as soon 
as the patient has warning, by the increased heat and irritation, 
that an exacerbation is impending. The nocturnal exacerba- 
tions were either stopped or greatly mitigated, and by repeti- 
tion, in some cases, a complete cure was effected, after the 
eruption had lasted for years. No eczema was ever excited in 
the neighborhood of the counter-irritant, even after severe 
blistering. The relief of the itching was so entire and imme- 
diate that the patient, after the first time, welcomed the repeti- 
tion of the treatment. Icebags to the spine have also been sug- 
gested for these cases. 

Local Treatment. — This is as important as the general treat- 
ment. Indeed, Hebra and the Vienna school place it first, and 
rely almost exclusively upon it. The judicious combination of 
the two finds most favor in English eyes, and appears to be at 
once the most rational and rapidly efficacious. 

The number of local remedies and plans of treatment for 
eczema is legion, and testifies to the troublesome and obstinate 
character of the complaint in many instances. I propose to 
limit myself either to those methods of treatment which have 
been most successful in my experience, or on which many au- 
thors of repute have placed their imprimatur. 

Except where the inflammation has been excited by para- 
sites, the local treatment is independent of the cause. The 
points to consider are the character and intensity of the inflam- 
mation, its position, and the secondary changes which have 
ensued. 

There are certain things which are always to be avoided. 
Eczema should never be washed with plain water, as most 
waters contain lime, which is irritating whenever there is any 
active inflammation, and will sometimes, if persisted in, render 
success impossible. Distilled water, pure water with scarcely 
any salts, such as that of Glasgow and Dublin, carefully col- 
lected rain water, are less injurious, also water which has been 
boiled and stood long enough to deposit the lime may be some- 
times used with impunity. 



222 DISEASES OF THE SKIN. 

The inflamed skin should always be protected from the air, 
and when it is on the face the patient should not go out in an 
east or northeast wind in this country, and should not be sent 
to the seaside as long as the eczema is out anywhere or has 
been out very recently. There are some exceptions to this. 
Thus, in strumous subjects, or some others who require bracing 
very much, the benefit to the general health more than counter- 
balances the local injurious effect, though even such patients 
would do better in an inland bracing climate. 

The first positive procedure in all cases should be to remove the 
crusts and scales completely, so that the remedy may be brought 
into absolute contact with the diseased surface. ' This may be 
done in various ways. The most common plan is to poultice 
the part for three or four hours. It answers well enough with 
care, but is so often overdone, and is then so injurious, that it 
is safer to avoid it altogether except in the form of the boric 
acid and starch poultice (F. Poultices), which Jamieson employs 
extensively. Plain almond or olive oil applied constantly on 
strips of flannel, until the crusts and scales can be softened 
enough to enable them to be readily detached, is the plan I 
prefer. Another good plan is to soak them off with decoction 
of marshmallow or thin gruel, to which 5ij of bicarbonate of 
soda to a quart are added. Some recommend india-rubber 
envelopes, but the parts must then, immediately after their re- 
moval, be wrapped in ointment, or the skin will crack as it 
dries. Where the crusts or scales are moderate in amount, 
the ointment selected may be applied at once, removing fresh 
scales night and morning, before the fresh dressing. When all 
the crusts are removed the inflamed part is ready for the special 
medication. 

The medicaments may be prescribed in the form of desiccant 
powders, lotions, liniments, pastes (hard and soft), and oint- 
ments. The drugs employed have soothing, astringent, anti- 
septic, stimulating, caustic, or keratolytic properties, and in 
selecting the remedy deemed appropriate the points to con- 
sider are the character and intensity of the inflammation, espe- 
cially as to the quantity or absence of discharge, and the posi- 
tion and secondary changes which have ensued, for, except 
where the inflammation is excited by parasites, the local treat- 
ment is independent of the cause. Speaking generally, in acute 



ECZEMA. 223 

or subacute eczema (as regards degree, not duration) the ap- 
plications should be continuous, while in the drier and more 
chronic forms they are intermittent. The objects are to secure 
equality of temperature and protection from the air and the 
injurious organisms it may contain, i. c, to keep the part 
aseptic; to constringe the dilated vessels and allow the excori- 
ated part to heal under the dressing; or, in the chronic forms v 
to remove the surface layers of thickened epidermis and 
sterilize the layers beneath. The treatment for special posi- 
tions will be considered separately. In all cases, when prac- 
ticable, the patient's convenience should be consulted, as he 
will often otherwise not carry out his instructions faithfully; 
besides, for the poor to give up working is often to give up 
eating. 

As a rule, lotions, unless they require to be applied con- 
stantly, are more convenient than ointments. Lotions or dust- 
ing powders are generally preferable where the discharge is 
very profuse, ointments may be used where the discharge is 
moderate, soft pastes where the discharge is slight, and hard 
pastes are suitable for dry areas. When a large moist surface 
has to be continuously enveloped, liniments find their place 
(see also p. 87). 

As long as there is great hyperemia and discharge, soothing 
remedies are safer, more grateful to the patient, never do harm, 
and are generally the most efficacious; non-irritating antiseptics 
may be usefully added. They act, too, chiefly by protecting 
the part from the air, etc. 

On the other hand, sometimes bolder measures, especially 
tar in some form, may effect a rapid cure in a comparatively 
acute case; but it is always risky in the early stage — may aggra- 
vate the inflammation, and thus destroy the patient's confidence 
at the commencement. It is a safe rule never to use strong 
remedies when the patient first comes under treatment, and 
until some knowledge of what his skin will bear has been 
gained. Stimulating, caustic, or keratolytic treatment is re- 
quired in chronic, indolent, scaly patches, or where there is 
thickening and great itching. 

The soothing remedies are mere emollients, such as boric 
acid and starch poultices, marshmallow decoction, or thin gruel 
with about oij of bicarbonate or biborate of soda to a quart. 



224 DISEASES OF THE SKIN. 

These latter make good washes where cleansing is necessary. 
Other emollients are olive and almond oil, ol. Deelinae, and 
other forms of heavy paraffin oils, or simple unguents. Those 
which are also astringents are various preparations of zinc, 
lead, bismuth, boric acid, alum, etc. Stimulating antiseptics 
are generally chosen from mercurial preparations, especially 
the ammoniated, the yellow oxid, the nitrate or oleate. Nitrate 
of silver, protargol, largin, resorcin, salicylic acid, ichthyol, 
thiol, etc., or tar or its derivatives in some form, are also used. 
Others less frequently employed will be alluded to presently. 
Lotions, such as calamin and bismuth, which contain sus- 
pended powders, are dabbed on and allowed to dry, leaving a 
powdery deposit which protects the inflamed skin. They are 
chiefly adapted for parts exposed to the air, and where the dis- 
charge is trifling or absent. They should not be used on the 
scalp, as they clog up the hair in a very disagreeable manner. 
In recurrent papular eczema they give great relief to the pruri- 
tus, and if used early and diligently, will cut short the attack in 
many cases. Soothing astringent lotions, such as the liquor 
or the glycerin of the subacetate or lactate of lead lotions, act 
best when continuously applied, so that the part may be rested 
and protected. 

Strong lotions, such as those of tar, nitrate of silver, per- 
manganate of potash, etc., require painting on once, twice, or 
thrice a day, according to their strength and the object in view. 

Soothing ointments and liniments should be applied thickly 
spread on lint or linen in strips, and then bandaged over, so 
that they may be closely and continuously applied to the part, 
and the ointment should be renewed about twice a day. Such 
applications merely smeared on twice a day are useless. 
Stimulating antiseptic ointments, unless very weak, seldom 
require continuous application. They may be used once or 
twice a day, according to the amount of stimulation required; 
but the part should always be protected from the air in the 
interval. 

Soft pastes, such as Lassar's zinc, starch, and vaselin, with 
one or two per cent, salicylic acid, are very valuable in subacute 
eczema without much discharge, but the salicylic acid must 
sometimes be omitted for a time, and boric acid, gr. 10 to 20, 
substituted. Ihle's (Pastes, F. 4) is a similar paste, with 



ECZEMA. 225 

resorcin and some lanolin. These and similar applications 
should be spread thickly on the part, and then covered with a 
many-tailed bandage of nainsook, butter-cloth, or similar 
porous material. The firm pastes contain gelatin and glycerin 
and zinc as a basis. Unna's (Pastes, F. 1) is one of the best; he 
generally adds ichthyol two per cent. If that kind of addition 
is required I prefer thiol, as it has no smell. Other antiseptics 
may be added as required. These pastes suit dry surfaces, or 
where there is but little discharge. The gallipot or tin is 
placed in boiling water, and the melted paste painted on with a 
stiff brush and dabbed with cotton wool to prevent the surface 
sticking to the clothing, etc. Pick's and Elliot's tragacanth 
varnishes (Pastes, F. 6 and 7) may be used in similar cases. 
They are easier to apply, as there is no melting required; but, 
on the whole, I like the gelatin preparation best, as it does not 
make the part feel stiff. 

Where the discharge is very profuse, desiccating powders 
may answer best ; they should be freely dredged on several times 
a day, removing the old powder where it tends to cake from the 
disccharge. Or they may be applied in Unna's bags (see p. 88). 
Except in the intertriginous eczema in the folds of fat people, 
I do not use powders very often where there is profuse dis- 
charge, as the caking of the discharge and the powder is much 
disliked by most patients. The powders most used are starch, 
kaolin, white peat, French chalk, lycopodium, etc., to which are 
added oxid of zinc, equal parts, the powdered oleate of zinc, one 
to three or four, finely ground boric acid, one to four or six; 
occasionally a little creasote may be beneficial, but it should be 
used with caution. 

In a widely spread eczema, where the discharge is not too 
profuse, swathing the patient in bandages dipped in calamin 
liniment is often soothing, efficacious, and convenient. When 
the discharge is very great, lactate of lead, one to fifteen, or 
glycerin of the subacetate, one to ten, would probably be most 
suitable; they should be warmed slightly, lest a chill should be 
produced by applying a cold lotion over a very wide surface. 
Even when an ointment might be otherwise suitable, to spread 
so much in strips would require a special attendant. When the 
active stage of the inflammation has ceased in a part of 
moderate extent, and there are only scaliness and moderate 
15 



226 DISEASES OF THE SKIN. 

hyperemia, mercurial preparations often suit best. Gr. 10 up 
to oj to the §j of the ammoniated or yellow oxid, alone or in 
combination, are the strengths chiefly used; they are very use- 
ful for scaly patches and for the head. The nitrate is generally 
used in the proportion of 5j of the ointment to 5vij of lard or 
white vaselin; it may be used in the same cases as the other 
mercurial applications. It is often a good plan, when the 
activity of the inflammation has subsided, to add a small pro- 
portion of the mercurial to the soothing remedy and increase it 
gradually. The oleate of mercury is not often used stronger 
than one or two per cent, in localized patches. To avoid sali- 
vation, mercurial applications must not be applied continuously 
or over too large an area. 

In pustular eczema, wherever situated, iodoform is the best 
remedy; 5 to 10 grains to an ounce of lard or any astringent 
ointment, such as zinc or lead, soon destroy the pus cocci, and 
alter the character of the eruption to a serous or dry eczema. 
Iodol or aristol act in a similar way, but are much less powerful 
and certain in their action, but I have found europhen useful; 
it is rather more irritating than iodoform, and one per cent, 
ointments are quite strong enough. Loretin is also useful, but 
rather irritating to some skins, even in one per cent, strength. 

Tar, in some form, is one of the most efficacious remedies in 
eczema, if used at the right stage, a point which requires much 
experience, and it is best to try it over a small area and see how 
it suits, before extending its use to the entire surface, for it is 
almost as powerful for harm as it is for good if wrongly used. 
It is not indicated until the acute stage is passed, and although 
it may sometimes be used when there is still discharge, there is 
always some risk in such cases. In the form of liquor carbonis 
detergens with subacetate of lead Mr. Hutchinson uses it in 
nearly all cases, only varying its dilution. 

It is in the squamous and papular forms that it acts best, re- 
lieving the intense irritation better than anything else. It may 
be used in a mild form, by adding a small quantity to the astrin- 
gent ointments, e. g., 3ss or 3j of the ung. picis, rr\iij to T!\x of 
ol. cadini or rusci, to §j of the weaker ointment, or in a lotion 
such as liquor plumbi subacetatis, liquor carbonis detergens, et 
glycerini aa 3ij, aquam ad gviij, or even weaker, applied three or 
four times a day, or carbolic acid TTLv to 5j of glycerin and rose 



ECZEMA. 



227 



water; or it may be used in a more vigorous manner, as recom- 
mended by Hebra: the pure wood tar, or ol. rusci or ol. cadini, 
is to be brushed firmly into a patch after the complete removal 
of the scales, and reapplied until a good thick coat of it adheres 
to the skin, and it is then allowed to separate spontaneously; it 
there is still much redness and desquamation, or weeping points 
and much itching, the tar must be painted on again. This kind 
of treatment is best suited for indolent patches, and the tar must 
be brushed in vigorously. For my own part, instead of letting 
the tar separate spontaneously, I prefer to let it be soaked off 
immediately by immersion of the patient or the limb in warm 
water for an hour or two; in short, what is called a tar bath. 
Or, where there is only a small area, the tar may be soaked off 
with strips of flannel dipped in olive oil. 

This is a most valuable treatment for chronic patches which 
have existed perhaps for many years. For scaly patches, with- 
out much infiltration, merely painting on a lotion of liquor car- 
bonis detergens and liquor plumbi subacetatis in equal parts, or 
nitrate of silver, gr. 10 or gr. 15 to gj of nitrous ether, is often 
sufficient, and relieves the itching, though it makes the skin 
tingle for a minute or two. Hebra's formula for scaly eczema 
of the face is a good one; acidi carbolici 5ij, glycerini, etheris 
aa 5j, spirit, vini rect. gvj ; but it must be used with caution at 
first until it is seen to suit, and, like all these strong prepara- 
tions, should never be used until milder measures have been 
tried and the patient's confidence is gained. 

Sulphur has a past reputation for eczema; locally, I rarely 
use it except as a weak ointment in E. barbae in the later stage, 
and in seborrheic dermatitis. Thilanin,* which contains three 
per cent, of sulphur, is an improved form of applying the drug, 
and is less irritating. Sulphur baths in the form of sulphid of 
potassium Jj to giv to thirty gallons are sometimes useful in 
the chronic folliculitis of the thighs, left sometimes after an 
acute eczema of those parts. 

For similar patches, salicylic acid may be usefully employed 
to promote the removal of the thickened skin, and I have some- 
times blistered the actual patch with great advantage. R. 

* Thilanin is obtained by the action of sulphur on lanolin, and forms 
yellowish-brown pomade of the consistence of lanolin. It was introduced 
to notice by E. Saalfeld. 



228 DISEASES OF THE SKIN. 

Simon of Birmingham advocates pilocarpin injections 1-8 grain 
for these cases. 

Sulphur springs, such as Harrogate, Strathpeffer, Aix-la- 
Chapelle, and Luchon, may be used in similar cases, and in 
chronic eczema generally; internally, they may be taken in 
gouty and rheumatic cases. As a rule, the local use of sul- 
phur aggravates all except seborrheic and chronic eczema. 
The alkaline waters of Ems, Roy at, and Vichy are more suita- 
ble than the sulphur springs, as a rule. 

Hebra's soap treatment is very valuable for patches of old 
standing with great infiltration, such as are ofteri seen about 
the legs and wrists. Have strips of lint or linen ready spread 
with oleate of zinc or lead ointment; then moisten a piece of 
flannel with water and spread a piece of soft soap as big as a 
walnut upon it, or dip it into the spiritus saponis alkalinus and 
rub firmly for some minutes, wetting the flannel with water 
occasionally, until all the scales are removed and the part is red 
with excoriated oozing points; then wash off the soap, dry the 
part rapidly, and immediately apply the ointment. The treat- 
ment may be repeated twice a day as long as there are any 
oozing red points left after the friction. In some cases the ad- 
dition of oil of cade, 5ij to the gj of the soap liniment, is useful 
where there is much induration. 

I have also found the treatment of Beissel of x\ix-la-Chapelle 
for chronic local eczema a good one: The crusts are thor- 
oughly soaked in oil at bedtime, and completely removed the 
next morning by alkaline lotions, such as bicarbonate of soda, 
3j to §vj. The reddened and perhaps freely discharging surface 
is then carefully dried, and painted with a one in ten solution 
of permanganate of potash; the painting is to be repeated once 
or twice a day, until a black scale of the thickness of a sheet of 
paper forms over the eczematous spot. At the end of a week 
the black crust is allowed to separate, and with the exception of 
perhaps a few fissures the cure is usually complete. This treat- 
ment can only be used where the part is covered, on account of 
the black disfigurement. 

The treatment of White of Boston is strongly recommended 
by Duhring for acute eczema. Lotio nigra of full strength, or 
diluted with equal parts of lime water, is applied to the part 
with a sponge for a quarter of an hour, allowing the black 



ECZEMA. 



229 



powder to remain on; then a little zinc ointment is smeared 
over, and the process is to be repeated every four or six hours. 

Ichthyol is strongly recommended by Unna of Hamburg for 
the treatment of eczema, and is largely employed by many in 
spite of its smell and dark color. Either as ointment or lotion, 
as it forms an emulsion with water, it is no doubt useful in 
obstinate moist circumscribed patches, such as are often seen 
on the hands and arms, and it is used from five to fifty per cent., 
the weaker preparations being preferable where there is dis- 
charge. Unna begins with a strong preparation and gradually 
reduces the strength. Ichthyol is least objectionable in combi- 
nation with the gelatin zinc paste, but it can also be used in 
combination with soft pastes like Lassar's, or in liniments like 
that of calamin. 

Thiol has a similar action, and is also black, but it has no 
smell, and I usually employ it instead of ichthyol, which is too 
disagreeable to have a large place in my practice. Remedies 
which do not stain or smell, and can be used without interfering 
with the patient's employment, should always have the 
preference. 

Picric acid in the form of a saturated watery solution (about 
one per cent, solution) has been recommended by MacLennan, 
Gaucher, and others in acute discharging eczema. The solu- 
tion is painted on or dabbed on with absorbent wool. It is 
said that itching and smarting immediately abate, and that it is 
not painful. The last statement is not correct; it often produces 
considerable smarting for ten to twenty minutes, and is very 
uncertain in its action, sometimes aggravating the inflammation 
instead of abating it. It should therefore be used tentatively 
over a small area, in case it should be unsuitable. I have 
chiefly used it in subacute cases, sometimes with success, but 
the proportion of failures was too great for its continuance in 
my practice. Some authors recommend that after painting the 
solution should be applied with wool soaked in it, and a dry pad 
of wool over that, but oiled silk must not be used, as macera- 
tion of the skin ensues. 

Having given a general account of different methods of treat- 
ment, it now only remains to state the modifications required, 
according to the position of the eruption. 

E. of the Head. In a child cut the hair short and soften the 



230 DISEASES OF THE SKIN. 

crusts with strips of flannel dipped in oil, and fasten them on 
with a calico cap for four or six hours; the crusts may then be 
removed by means of a comb or the fingers, or where they are 
much matted, by cutting the hair under them. If it is a case of 
E. pustulosum, an iodoform or iodol ointment, gr. 5 to §j of 
vaselin or lard, spread on strips of lint and kept on with the 
cap as before, will be the best, renewing night and morning, 
after wiping off the old ointment. In a week or so the pustular 
element will be removed, and the eruption will be dry, or at 
most serous; oleate of zinc, or lead, or boric acid oss to §j may 
then be substituted for the iodoform, with later perhaps a few 
grains of ammoniated mercury added. In E. vesiculosum 
these ointments may be used at once. Boric acid and starch 
poultices are used by Jamieson for preliminary cleansing pur- 
poses, and these are safe and efficient, but linseed and bread 
poultices should be absolutely tabooed, as they too often serve 
as nutrient media for pus and other cocci. 

In adults the ointment may be applied with the finger as di- 
rectly as possible to the scalp, and when the acuteness of the 
inflammation has subsided the mixed ammoniated and yellow 
oxid of mercury may be used of various strengths, from gr. 10 
to 5ss of each, according to the degree of inflammation. 
Where there is great irritation a few minims of oil of cade to 
the 5j is a good addition; the hairs should be extracted where 
there is pustular inflammation round them. 

In some adult cases of pustular eczema capitis a lotion of 
glycerini plumbi subacetatis 5 SS > liq. carbonis detergentis 3fss, 
aq. rosse ad §vj acts admirably. 

E. of the Ears. The redness and swelling are often very 
great. Calamin liniment freely applied and painted inside the 
meatus several times a day generally gives relief; lactate of lead 
lotion, or glycerin of the subacetate of lead, one to ten, are also 
good applications, always with protection against tempera- 
ture changes. Acidi borici 5j, pulv. amyli. zinci oxidi aa §ss is 
a good dusting powder. 

E. of the Face. In infants lead, zinc, or boric acid ointments, 
or Lassar's paste, are usually preferable, and in most cases the 
oleate of zinc is preferable to the oxid. Here again, the oint- 
ment should be applied continuously under a mask, and here, 
as in all infantile eczema, the great trouble is to prevent scratch- 



ECZEMA. 231 

ing, which often frustrates all curative measures. Whenever it 
appears irritable, the rag should be raised and almond oil 
painted on, and the rag replaced. The hands at night must be 
restrained, and in very obstinate cases it may be necessary to 
bandage them to the sides of the body, like a mummy. They 
seldom resent the confinement after the first few hours. In 
some cases the zinc, starch, and boric acid powder already 
mentioned suits well when dusted thickly on. 

In adults, unless the discharge is very profuse, calamin lotion 
agrees well and is very convenient; if it is too drying, calamin 
liniment may be substituted, or some other greasy, soothing 
astringent. The glycerin of subacetate of lead is cleanly and 
comfortable, but in some cases the glycerin disagrees. When 
the acute inflammation has subsided, the addition of some 
liquor carbonis detergens is often desirable, beginning with TI\v 
to the gj and increasing as may be found necessary. 

E. of the Eyelids, or Blepharitis, is common in strumous chil- 
dren. The crusts must be softened with oil, picked off, the 
hairs extracted, and ung. hyd. nitratis, 1 to 8, smeared along 
the edges. In obstinate cases McCall Anderson's plan of 
painting liq. potassae gr. 10 to gj carefully along the edges, 
after protruding and everting them between the thumb and 
finger, is valuable. The action of the alkali may be restrained 
in a few seconds with weak acetic acid and water, and the 
process repeated every few days, with the dilute nitrate of mer- 
cury ointment in the intervals. Suitable constitutional treat- 
ment should always be employed. Where the mercurial oint- 
ment cannot be borne, boric acid ointment oss to gj may be 
used. 

E. of the Lips is troublesome, and leads to Assuring, on ac- 
count of the constant mobility. The frequent, often uncon- 
scious, licking of the dry lips is an aggravation. 

The frequent application of soothing remedies, e. g., liq. 
plumbi subacet. Tr[xv to gj of white vaselin or lard, may be 
tried, or plumbi carb. gr. 15, cremor. frigid, gj should be fre- 
quently applied, and always after licking the lips. 

If these fail, Hebra's carbolic lotion referred to may be 
painted on, or nitrate of silver in nitrous ether may be re- 
sorted to. 

E. of the Beard. When the hairy part of the face is affected 



232 DISEASES OF THE SKIN. 

shaving should be insisted on as soon as the acute stage is 
over, if not before; it is not so painful as might be anticipated, 
and if the patient is once prevailed upon to do it, there will be 
no further difficulty in keeping it shaved. Where there are 
pustules the hair should be extracted; when it is acute, soothing 
remedies must be employed as continuously as possible; after- 
wards hyd. oleate one or two per cent., weak sulphur ointment 
gr. 5 to gr. 20 to §j, or ung. hyd. nitrat. dilut., are the most 
suitable; in short, the treatment for sycosis is applicable here. 

In very old-standing cases multiple linear scarification of 
the whole surface is a very valuable preliminary, the surface 
being subsequently dressed with iodoform gr. 5 to gr. 10 to 
ung. acidi borici §j : the scarification may have to be repeated. 
Cases of many years' duration may be cured by this method. 

E. of the Arms offers no special difficulty; soothing astrin- 
gents and antiseptics in pastes or ointments can always be con- 
tinuously applied with a bandage when acute, while in the 
chronic scaly patches, nitrate of silver, liq. carbonis detergens 
and lead, etc., or oil of cade, may be painted on. The papular 
forms are very common here, and bear tar well, but when there 
are only fresh papules breaking out continually, calamin lotion 
is often sufficient. 

E. of the Palms is always troublesome, on account of the con- 
stant movement, and also because the natural thickness of the 
epidermis is increased by disease. In all cases it is essential to 
remove the thick epidermis, as otherwise medicaments are use- 
less. This may be done by mechanical or chemical means. 
The hard skin may be rubbed down with pumice stone or fine 
sandpaper. Unna's plan of applying salicylic acid plaster, re- 
newing every two or three days, is an excellent one; the whole 
thickened epidermis may be peeled off in this way. Another 
plan I have found work well is to apply a pancreatic emulsion 
constantly on lint; this disintegrates the cuticle, and much 
facilitates removal. Morris suggested papain with the same 
object, but it is not so powerful. Pepsin is also not so 
effectual, and is less suitable, as it requires an acid medium to 
act in, while the others act in an alkaline fluid. 

After the epidermis is removed salicylic acid gr. 10 to 3j to 
5j is one of the best remedies; here the gelatin zinc paste is 
very useful as a base, as it can be kept on without trouble, and 



ECZEMA. 233 

only requires renewing once in twenty-four hours. Painting 
with Stockholm tar and then soaking it off with olive oil is 
often most valuable. Thiol and ichthyol are also said to have 
a powerful effect in diminishing thickening, and there is no 
harm in prescribing them, preferably along with salicylic acid, 
but I have not had convincing proof of their effect in this direc- 
tion, though I have often tried them. When the inflammation 
is at all acute, soothing applications are best. When the fin- 
gers are affected each one should be dressed separately. Mer- 
curial ointments, the oleate especially, are useful for E. palmse, 
but they must not be applied continuously. 

E. of the Nails is always a very slow affair, as it is so difficult 
to get at the matrix; wrapping the ends up in ung. picis con- 
tinually is often very useful, but disagreeable; less objectionable 
is salicylic acid ointment oss to Jj. It may be pushed under the 
nail fold. It has to be used intermittently, as the skin gets 
sore. As a rule, patients can only give up one or two fingers 
at a time to treatment. Shoemaker recommends oleate of tin 
5j to the 5J. A weaker preparation gives a luster to the nail, 
according to him. 

E. of the Genitals is one of the most distressing varieties for 
the patient, and the most troublesome for the attendant. On 
the scrotum, when acute, ointments seldom succeed except 
sometimes a weak boric acid ointment. Calamin liniment, or 
lotion, or the lactate of lead often answers well. Jackson is a 
strong advocate for sheet-rubber envelopes. The itching, 
which is quite maddening sometimes, may be relieved by paint- 
ing on the nitrate of silver solution, gr. 5 to 15 to the §j of 
nitrous ether, or by Bulkley's plan of applying a handkerchief 
dipped in water as hot as can be borne for two or three minutes, 
not more, then drying, and putting on the local application 
selected, at once. This I have found very successful some- 
times, and it has secured a night's rest; but better than all is the 
application of a mustard leaf over the lumbar enlargement; 
this relieves the intense pruritus more completely and for a 
longer period than anything else. 

When on the penis the lead and liq. carbonis detergens 
lotion, applied two or three times a day, is a good remedy in 
many cases. 

E. of the Vulva is not quite so troublesome as that of the 



234 DISEASES OF THE SKIN. 

scrotum, though bad enough. Calamin liniment or lactate of 
lead is useful here also, but the nitrate of silver solution, not 
more than gr. 5 to the §j of nitrous ether at first, is probably 
the best application; as a rule, the smarting only lasts a few 
minutes; of course, the possibility of its being due to diabetes 
mellitus must be borne in mind, and if glycosuria is present, 
constitutional treatment in accordance with it must be 
adopted. Uterine or ovarian irritation, if present, should also 
be removed. 

E. of the Legs. In all cases of eczema below the knee rest in 
a horizontal position is an important adjuvant, especially if 
there are varicose veins; bandaging carefully from the foot up- 
wards is the best alternative to rest, but I do not care for 
Martin's rubber bandages, except when there is an ele- 
phantiasis condition or tendency to papillary hypertrophy. 
Boric acid ointment 5ss to §j is one of the most generally ap- 
plicable, unless the discharge is very profuse, when a lead lotion 
of some kind is better. I use chiefly the glycerin of the sub- 
acetate, 1 to 8, but sometimes the lactate is preferable. 

For chronic patches on the knee or popliteal space the tar 
and olive oil or Hebra's soap treatment are the best. The 
gelatin zinc paste is a very convenient application for these 
parts if the surface is not too moist. 

E. Circumscriptum (?) Parasiticum. I venture to give this 
name to the form of eruption which looks like a dry eczema, 
but its border is more sharply defined than is usual in E. 
squamosum. It occurs chiefly on the legs, especially below the 
knee, but I have seen it * on the arms. It is made up of minute 
papules, which aggregate into a pretty uniform, moderately red, 
scaly patch, with sharply defined borders, and perhaps outly- 
ing papules; it remains for years, if untreated, slowly extend- 
ing or forming fresh patches, and is not symmetrical; there is 
moderate itching. I have not succeeded in demonstrating a 
parasite, but a weak parasiticide ointment cures it, such as 
sulphur, sublim. gr. 20, acid, carbolic. TTLxv, adip. benz. §j. 

Hans Hebra f has described a parasitic eczematous eruption, 

*M. , set. fifteen, private note book, vol. i. p. 165. 

f Wien. med. Blatter, 39 and 40, 1881. Abs. Ann. de Derm, et de 
Syfih., 1883, p. 142. 



DERMATITIS REP ENS. 235 

but it is accompanied with weeping and crusts, and is very 
chronic, if untreated. It is situated in the flexures of the 
elbows and knees, and on the neck. He treats it with Wilkin- 
son's sulphur ointment, or with first a ten per cent, pyrogallic 
acid ointment, and afterwards a five per cent, alcoholic solution 
of salicylic acid. 

Epidemic Eczema. See Epidemic Exfoliative Dermatitis. 

DERMATITIS REPENS. 

Definition. — A spreading dermatitis, usually following in- 
juries, and probably neuritic, commencing almost exclusively 
in the upper extremities. 

Since I first described this disease in 1888 * from three cases, 
it has become recognized by other observers, and some addi- 
tional facts have been gained which throw a little more light 
on its real nature. Dr. Garden of Aberdeen, Mr. Charlton of 
Salisbury, and Dr. Coward of Almondbury, have sent me photo- 
graphs or drawings of typical cases, and I have now seen over 
a dozen cases, all of them remarkably alike, except as to their 
extent. I have also seen three cases of a dry form. 

Nepveu f read a case at the French Congress of Surgery in 
1886 which probably belongs to this category. The patient 
was a woman, in whom a vesicular eruption, commencing in a 
superficial wound of the thumb, spread over the whole body. 
Bacteria were found in the vesicles, and the disease was checked 
by an iodoform dressing. 

In all the cases in which inquiry has been made, an injury, 
often a trivial one, has been the exciting cause. Vesicles or a 
bulla have appeared at the site of the injury, and these have 
ruptured and the elevated epidermis been thrown off, leaving a 
bright red surface, oozing a clear or slightly turbid fluid. The 
border of the denuded area is bounded by a collar of the epi- 
dermis, which is raised up by subjacent fluid, clear or turbid, 
and is sodden and irregular. Sometimes extension takes place 

* In the first edition of this work, with an account of the three cases. 
I also read a paper on it a L the Derm. Congress at Vienna in 1893. 
Stowers' case is now referred to acrodermatitis perstans. 

f Paris correspondence, Brit. Med. Jour., December 11, 1886. 



236 DISEASES OF THE SKIN. 

by the continued detachment of the epidermis by further exu- 
dation, or there may be fresh vesicles or small bullae just be- 
yond the border, which break down and add a newly denuded 
area to the original adjacent one. Although new adjacent foci 
may thus be formed, the disease does not generalize by the 
formation of new distant foci. Cases may last for weeks, 
months, or even years. 

The extent of the disease varies greatly; in the majority it 
does not extend beyond the hand first attacked; but my first 
case extended to the elbow, my second began on the wrist, and 
extended down to the hand and up the arm, across the back of 
the neck, and down the left arm to the elbow, the old parts 
healing while there was fresh extension. It lasted nearly a 
year. Other cases have been more amenable than these, but 
they have always given a great deal of trouble to cure. 

Dry Form. — In three cases a very similar condition was 
present, with slow peripheral extension and undermined epi- 
dermic border, but the inflamed part was dry throughout. In 
two there was a history of previous syphilis, and in the third it 
could not be excluded. In all of them a trivial injury was the 
exciting factor, and their general course was, like the others, 
quite uninfluenced by internal specific treatment. One of them 
was particularly obstinate, and lasted nearly two years, in spite 
of specific treatment, local and general, and of varied local 
treatment, such as is ultimately successful in non-specific cases. 

Acrodermatitis Perstans. Hallopeau * has described, under 
the French equivalent of the above title, a condition closely 
allied, in its symptomatology at all events, to dermatitis repens. 
Stowers f and Freche % have each described a case, the sequel 
of Freche's case being Case IV. of Hallopeau; and Audry § has 
published three cases. 

* Hallopeau, " Les Acrodermites Continues," Revue Generate de 
Clinique et de Therapeutique, February 12, 1898, and p. 838 of Hallopeau 
and Leredde. 

f Stowers, "Notes on a Case of Dermatitis Repens," Brit. Jour. Derm., 
vol. viii., 1898, p. 1. Colored plate. 

^Freche, "Eruption Trophonevrotique des Extremites rappelant la 
Dermatitis Repens," Annates, de Derm, et de Syph. y vol. viii., 1897, 

p. 49T. 

§ Audry, " Les Phlyctenoses Recidivantes des Extremites," Annates de 
Derm, et de Syfih., vol. ii., 1901, p. 913, republishes all previous cases, 



DERMATITIS REP ENS. 237 

Hallopeau distinguishes a vesicular, bullous, and a purulent 
type, and a mixed form (Audry's case). The disease, like der- 
matitis repens, begins on one finger or thumb, and may be 
limited to it for a long time; then others are successively in- 
volved, and it may spread to the palm, less often to the back, 
but the whole hand is rarely involved. The vesicular form has 
not so far attacked the toes, while the pustular has done so. 
In both the nails are liable to be affected, by thickening, furrow- 
ing, pitting, and discoloration, in some cases followed by com- 
plete loss. The oral mucous membrane and tongue have been 
attacked in two cases. The initial lesions are vesicles or pus- 
tular phlyctenular on a reddened base, which rupture after a 
time and leave excoriations, and some have apparently started 
from whitlows, and in some an injury has been the immediate 
antecedent. The disease is usually confined to the extremities, 
chiefly the hands, but secondary eruptions may arise in the pus- 
tular form, by the development of fresh foci and not by con- 
tinuity, on any part or even over the whole body, and in one 
case (Freche-Hallopeau) a fatal impetigo herpetiformis devel- 
oped. The secondary eruption may be erythematous and des- 
quamating, like pityriasis rubra, instead of pustular. These 
secondary eruptions are symmetrical, and affect especially the 
neck, arms, elbows, wrists, scrotum, and knees, ankles and 
lower part of the legs, but no part, including the scalp, is 
exempt. The skin lesions on the extremities exactly corre- 
spond in the vesicular forms with dermatitis repens, but have 
less tendency to spread beyond the hand than the latter. Many 
cases of dermatitis repens have never spread beyond the hand, 
and Hallopeau is not justified in claiming such cases as his 
acrodermatitis on this point alone. More valid grounds are 
the tendency of acrodermatitis to be kept up indefinitely by 
recurrences in the same place, while dermatitis repens is kept 
up by continuous extension, the original place healing, though 
very slowly. Acrodermatitis, when secondarily attacking parts 

and adds two more, ten in all. In vol. viii., 1897, p. 141, he proposed a 
classification of diseases attacking the extremities — " acrodermites." But 
classifications on such small bases are too like an inverted cone to be of 
practical value. 

M. Carle reports a case of five years' persistence apparently cured by 
electro-cautery. Loc. czl., vol. iii., 1902, p. 130. 



238 DISEASES OF THE SKIN. 

other than the extremities, does so by the development of fresh 
foci, and large areas are produced by the coalescence of several 
such foci. It is also more persistent, and may be fatal ulti- 
mately. On the other hand, they resemble each other by both 
attacking and being often limited to the extremities; in the" 
similarity of the skin lesion; by the slow evolution; by the fre- 
quency of a traumatism being the starting-point; and by their 
rebelliousness to treatment, though dermatitis repens does 
eventually get well. Moreover, when healing has taken place 
there is not the same tendency to recur in the same place in 
dermatitis repens. 

Pathogeny. — The cases tend to show that the dermatitis starts 
as a result of a peripheral neuritis, generally set up by an injury 
often quite trivial; and since antiseptics are generally eventually 
successful, it is probable that secondary parasitic invasion tends 
to produce extension of the disease, a view with which Audry 
agrees; but Hallopeau regards this and acrodermatitis perstans 
as entirely of microbic origin. The staphylococcus albus has 
been repeatedly found in several of his cases. 

Diagnosis. — The distinctions between dermatitis repens and 
acrodermatitis perstans have been sufficiently drawn. The 
only other disease for which dermatitis repens may be mis- 
taken is eczema. From this it differs in its purely local origin; 
its unilateral limitation, at all events for a long time; its ab- 
sence of tendency to form new foci, except close to the main 
seat of disease; in the sharply defined border with undermined 
edge of sodden epidermis; the complete denudation of the epi- 
'dermis on the part over which it has traveled; and in the ab- 
sence of marked itching and burning. Iodoform dermatitis 
may somewhat resemble it, but the distinctions are much the 
same as from eczema, and there would generally be evidence of 
contact with the drug. 

Prognosis. — All the cases have got well ultimately, but some 
have been very rebellious to treatment. With regard to acro- 
dermatitis perstans the prognosis is not so good. Constant 
recurrences keep the disease up for years, crippling the patient, 
and a fatal result has ensued in the Freche-Hallopeau case, in 
which impetigo herpetiformis supervened. Stowers' case lasted 
forty-five years, when the patient died of abdominal cancer. 
All the A. perstans cases have been of long duration. 



DISEASES DUE TO PUS COCCI. 239 

Treatment. — The usual soothing applications for acute 
eczema are nearly always useless in dermatitis repens,. except 
the lactate of lead lotion, which has been successful in arrest- 
ing the disease in some cases; but the most efficacious treat- 
ment in my experience is to cut away the undermined epi- 
dermis, and paint on once a day a ten per cent, solution of per- 
manganate of potash and let it dry, repeating it daily for a 
week, when a black crust is formed, which can be detached in 
a few days. This is Beissel's treatment for eczema, and re- 
quires to be repeated to various parts where the disease is not 
killed. 

A one per cent, solution of nitrate of silver in spirit of nitrous 
ether was thoroughly tried in my first case without success, 
while Hallopeau found it in a 1 in 8 solution one of the best 
remedies for acrodermatitis perstans. In the purulent form 
he thought the fluid called laurenol was better still; it is a 
medley of sulphate of copper, chlorid of zinc, alum, chlorid of 
potash, chlorid of sodium, picric acid, boric acid, and hydro- 
chloric acid. A three per cent, solution was applied on com- 
presses; under this the suppuration disappeared for a time, but 
usually recurred; but once a permanent cure was effected. 

In some cases of dermatitis repens rubbing in iodoform has 
succeeded in arresting the disease. 

In the dry form rubbing on unguentum hydrargyri has a 
good effect for a time, but in the obstinate case before men- 
tioned the treatment ultimately successful was to apply Unna's 
salicylic and creasote plaster to the edge, until the scaly collar 
could be softened and removed. Then a compress of 1 in 4000 
perchlorid was applied till the part was sore, and then boric 
acid ointment put on to heal it. By these means perseveringly 
followed up the border was ultimately healed up. 

DISEASES DUE TO PUS COCCI. 

Modern research has shown that pyogenic organisms play an 
important part in the production of numerous inflammatory 
diseases of the skin, for the most part with pustular lesions. 

The pus cocci include not only the familiar staphylococci, but 
the streptococci; and most eruptions with pustular lesions are 
caused by one or other of these genera, and it is the eruptions 
produced by them which are now to be considered. 



240 



DISEASES OF THE SKIN. 



The clinical variation is doubtless, in most cases, the result 
of the anatomical difference in the path of introduction. In 
impetigo contagiosa, the cocci gain entrance through the epi- 
dermis, abraded through scratching or otherwise; the inflam- 
mation is limited to the papillary layer, and on the destruction 
of the materies morbi the lesion heals readily without scar. In 
boils and carbuncles the mode of entrance is by the hair fol- 
licles and sebaceous gland orifices, but in carbuncle the cocci 
penetrate below the cutis into the planes of connective tissue, 
which accounts for its frequent disastrous extension. 

Sweat boils have hitherto not been shown to be due to pus 
cocci. The opportunities for the investigation are fewer, and 
attempts to discover the cause have been hitherto negative, so 
at present it can only be inferred by analogy. In folliculitis 
the cocci are limited to the hair follicle and its immediate 
neighborhood. 

There are also other organisms which sometimes produce 
pustular lesions without the intervention of pus cocci, and must 
therefore be considered as pyogenic. Such are the Trichophy- 
ton megalosporon, ectothrix and endothrix, the former most 
frequently; the acne bacillus, blastomyces, and the tubercle 
bacillus. The diseases produced by them are described in their 
respective sections. 

Boils. 

Carbuncles. 

Coccogenic Sycosis. 

Lupoid Sycosis. 

Impetigo of Bockhart, and secondarily in 
other forms. 

Quinquaud's "Folliculitis Decalvans." 

Dermatitis Papularis Capillitii, and prob- 
ably other forms of pustular folliculitis. 

Pemiphgus Neonatorum. 

Pemphigus (Contagious). 

Cutaneous Abscesses. 

Superficial Whitlows. 

Erysipelas.* 

Granuloma Pyrogenicum, and ot-her fungat- 
ing papillary growths. 

Acne Varioloformis, seu Necrotica. 
* While erysipelas in man is usually produced by streptococci, Jordan 
has shown that it may also be produced by staphylococci, and in rabbits 
even by pneumococci and bacterium coli commune. 



Staphylococcus aureus, j 
albus, citreus. 



IMPETIGO. 



241 



The accompanying tables show the respective roles of the 
genera of pus cocci according to the most modern views; but, 
as will be shown, when considering the pathology of each affec- 
tion, absolute proof that they are really the pathogenic organ- 
ism is wanting in some of the diseases. 

Secondary staphylococcal invasion occurs in impetigo con- 
tagiosa, if Sabouraud's views are correct, in pustular eczema, 
and various forms of pustular dermatitis. 

f Impetigo Contagiosa, and its varieties, in- 
cluding Ecthyma, but excepting Bock- 
Streptococcus pyogenes * J hart s - 

" ofFehleisen | Erysipelas. 

Erysipeloid. 
Superficial Whitlows.* 

IMPETIGO. 

Deriv. — Impcterc, to attack. 

This term was used by the older writers for various forms 
of pustular dermatitis, chiefly eczematous, the formation of pus 
constituting, in their view, a special disease. Willan and Bate- 
man described five varieties: I. figurata, sparsa, scabida, ery- 
sipelatoides and rodens; the first four were eczematous, or im- 
petigo contagiosa, the last was probably tertiary syphilitic 
ulceration, or sometimes rodent ulcer. Other obsolete varie- 
ties by later authors need not even be mentioned, as all these 
terms are now discarded; there remains only the impetigo con- 
tagiosa of Tilbury Fox and that of Bockhart. 

The term impetigo J should not be employed without its ex- 
planatory affix, as by itself it conveys no definite meaning. 

* These two are said by some authors to be identical; by others to be 
different organisms. 

f Gilchrist found both streptococci and staphylococci. 

\ Duhring has described under "Impetigo" what he considers a 
separate affection, but after long observation I am unable to separate it 
from I. contagiosa. It is said to be pustular from the first, more deep- 
seated, and therefore has a thicker and more rounded roof to the lesion, 
remains discrete, and is not contagious; to the last attribute I strongly 
demur. Its treatment is the same as that for I. contagiosa. It corre- 
sponds in some respects to Bockhart's impetigo, but the latter is always 
follicular. 
16 



242 DISEASES OF THE SKIN. 

IMPETIGO CONTAGIOSA.* 

Synonym. — Porrigo contagiosa. 

Definition. — Discrete vesicles or pustules, due to inoculation, 
with contagious pus. 

This is an important eruption, on account of its great fre- 
quency and liability to be mistaken for eczema. It was de- 
scribed independently by the late Mr. Startin and Dr. Tilbury 
Fox, the latter laying stress upon one phase of it, in which it 
occurs pseudo-epidemically, chiefly in the children of the poor. 
This form is one of the conditions reported from time to time 
as " epidemic pemphigus." 

Symptoms. — In the common run of cases primarily, the erup- 
tion is a flat vesicle or " watery head," from a pea to a finger 
nail in size, which is soon converted into a flat, irregularly out- 
lined pustule. The contents dry up into a yellow at first, and 
later into a greenish scab, completely covering the excoriated 
surface, and there being no red areola, the scab has the appear- 
ance of being " stuck on," as Fox expressed it. 

The position of the lesions is usually due to the implantation 
of the pyogenic organisms by the finger nails in the act of 
scratching; and while the most common positions are round the 
mouth, chin, nostrils, and occipital region, they may occur in 
any part accessible to the finger nails. Chiefly from friction, 
fresh lesions arise near the original ones, and they may coalesce 
into small or large patches, and look like a crusted eczema, but 
discrete isolated lesions are almost invariably to be found in the 
neighborhood. 

A few isolated pustules are often found on the hands and 
other exposed parts, and superficial whitlows may be present 
at the finger-ends. In the occiput pediculi are the irritants 
which lead to scratching, and the pus dries into greenish-black 
scabs, matting the hair together, and producing so much irri- 
tation in the neighboring glands that they enlarge, inflame, and 
sometimes even suppurate. 

Variations. — It must be remembered that there are all grades 
of severity and extent of the eruption, which modify its ap- 

* Author's Atlas, Plates XII., XIII., and XIV., illustrate the ordinary, 
bullous, and gyrate forms of impetigo contagiosa and of ecthyma. 



IMPETIGO CONTAGIOSA. 243 

pearance considerably. Thus, there may be a few discrete 
lesions only, or they may be combined with extensive patches, 
or the eruption may spread widely and rapidly over the body, 
and then is usually vesicular in the main. 

The lesions also vary much in size and contents, they may be 
from a hemp seed to a finger nail, and while usually flattish in 
elevation, occasionally form large projecting bullae, either pri- 
marily or from coalescence. The rule is for them to begin as 
vesicles, and become vesic'ulo-pustular and pustular at a later 
period, but they may be vesiculo-pustular or pustular from the 
first, without being situated at a hair follicle, the latter espe- 
cially in cachectic children. 

On the other hand, I have seen the eruption in adults as red 
raised irregular papules, or patches one-third of an inch or 
more across, extremely irritable, and scratched into an excoria- 
tion at the top, but none of them distinctly vesicular or pustu- 
lar; bullous and pustular lesions may, however, occur in adults. 

It is also modified by position; face lesions seldom have an 
areola, but when it occurs on the limbs, it is very liable to be 
rubbed, then the pustules get ruptured, covered with a flat, 
irregular scab, and surrounded by a more or less prominent 
areola.* Lesions of this kind used to be considered to be of a 
different nature, and were called ecthyma, but their associa- 
tion with the more typical aspect of the disease on the face is 
too frequent for there to be any doubt that they are the same 
eruption altered by friction, to which it is more exposed on the 
limbs than it is on the face. 

The epidemic form is ushered in by transitory febrile symp- 
toms, and comes out in crops of vesicles for about a week; it 
then dries up and runs its course in a fortnight. No line can, 
however, be drawn between these cases and the far more com- 
mon condition in which there are no febrile symptoms, while 
the eruption is more limited, and does not, as a whole, run a 
definite course. It is almost certain that, in these rapidly de- 
veloping generalized forms, the pus cocci get into the circula- 
tion, and thus spread the eruption all over the body, and their 
toxins, when they are numerous, produce the febrile symptoms. 

*Sabouraud states that the impetigo contagiosa of T. Fox is always 
primarily vesicular, but this is only true as a general statement, to which 
there are many exceptions. 



244 DISEASES OF THE SKIN. 

There is little doubt that most, if not all, of the localized epi- 
demics of what are commonly reported as pemphigus con- 
tagiosa are really the impetigo contagiosa of the epidemic 
form of Tilbury Fox. 

Impetigo contagiosa bullosa in the sporadic form only dif- 
fers from the ordinary type in the lesions being larger, circu- 
lar * flat bullae, with narrow areola in some cases ; the bullae 
are more convex, and closely resemble ordinary pemphigus in 
form, but do not run the course of that disease. 

Impetigo Contagiosa Gyrata. In July, 1894, t I met with a 
gyrate form for the first time. In that and the following year 
other cases, but less marked, appeared in the practice of others 
as well as in my own, but they have since ceased to occur ex- 
cept with very slight development. Apparently similar cases 
have, however, been reported from America J and India under 
other names. The only explanation I can suggest is that the 
variation developed in the great heat of the summer of 1893, 
and has gradually disappeared, and it is now again only to be 
found in hot climates. 

In this form the initial lesions vary from a hemp seed to half 
an inch in diameter, and form small flaccid bullae with sero- 
purulent contents. As they enlarge peripherally they become 
ruptured with a red areola inclosing a border raised up by fluid, 
and within that is a thin, flaky crust of a greenish hue, which 
forms another circle with a ragged inner edge, while the central 
part, in those sufficiently large, heals completely. 

Impetigo of Bockhart is a pustular folliculitis, but is de- 
scribed here for convenience of comparison. This form, ac- 
cording to Sabouraud, differs from that of Tilbury Fox in being 
always primarily pustular, situated at a hair follicle, and due to 
a different organism, viz., staphylococcus aureus and albus. It 

*This form in flat bullae is well depicted in Tilbury Fox's Atlas, Plate 
XXIV. 

f I read a paper on " Impetigo Contagiosa Gyrata " in Clin. Soc. Trans., 
vol. xxix., 1896, with colored plate. The case is also illustrated in Plate 
XIV. of my Atlas. 

% " On Impetigo Contagiosa Annulata," Schamburg, Amer. Jour. Cut. 
and Gen.-Ur. Dis., vol. xiv., 1896, p. 169, he refers to Plate VII. of 
Raver's Atlas, but it is questionable it if was the same disease. 



IMPETIGO CONTAGIOSA. 245 

begins as round pustules with a long or coarse hair in the 
center, and its especial site is on the hairy scalp at the vertex or 
parietal region, and the pustules vary from minute pustules to 
the tip of the finger in size. Its onset is sudden as a crop of 
follicular pustules, and it is accompanied, or even preceded, by 
glandular enlargement of the neck. It lasts some days, reach- 
ing its acme in two weeks, and subsides in three weeks with 
falling off of the crusts. The pustules are seldom ruptured by 
scratching, and many dry up without breaking. Sometimes 
deep folliculitis ensues with true furuncles or even abscesses. 

Successive crops of pustules and relapses are frequent. 
Other regions less frequently attacked are the neck, face, back, 
buttocks, and thighs, and it may start in those places. It is the 
precursor of all furuncular eruptions and frequently com- 
plicates the impetigo of Tilbury Fox, sometimes in the form of 
miliary pustules with a hair in the center of each. 

It is related to acne capillaris of adults, acne necrotica, furun- 
culosis, suppurative acne, iodid acne, traumatic and pustular 
dermatitis. 

Such are the description and views of Sabouraud, but with 
much of this I cannot agree. While pustular folliculitis as 
described is found very often on the occipito-vertex regions of 
the scalp with enlarged cervical glands, the lesions are almost 
entirely due to the scratching induced by the presence of 
pediculi capitis as previously described, and the glandular en- 
largement does not precede, but follows, the pustular develop- 
ment. I strongly doubt whether these scalp lesions are really 
due to a different disease and organism from that described by 
Tilbury Fox, the pustular character being largely due to posi- 
tion, which is more favorable to the development of pus- 
organisms than the skin of the face. 

Sabouraud accounts for the different lesions being so con- 
stantly associated by asserting that Bockhart's impetigo fre- 
quently complicates that of Tilbury Fox. The simpler expla- 
nation, that they are only variants of the same disease, is not 
yet conclusively disposed of, as will be seen under the Pathol- 
ogy section. 

Etiology. — Out of four hundred cases seen by the late Mr. 
Startin, three-fourths were children under seven years of age, 
and only twenty-seven were adults. It is chiefly seen among 



246 DISEASES OF THE SKIN. 

the poor, and is always due to the inoculation of contagious 
pus, independently of its source. Scratching easily leads to 
purulent lesions in children; hence pediculi capitis are a very 
common cause of I. contagiosa. Scabies and urticaria occur- 
ring mainly on the trunk and limbs, the lesions generally 
assume the so-called ecthymatous character. In a medical 
student I traced an acute, general outbreak, mainly vesicular, 
to the irritation of the harvest bug. Of course, it may also be 
propagated from one person to another. Much has been said 
of its frequently following on vaccination, but this is only an- 
other instance of pus inoculation; the vaccine lesion is often 
very itchy in its purulent stage, the child scratches it, and trans- 
fers the pus to other parts of the body. 

A few years ago there was much discussion on what was 
called " football impetigo," or, as the schoolboys called it, 

^ ® < 

OHonq 

Fig. 15. — Micrococci of Impetigo Contagiosa. X550. 

" scrum-pox." It is ordinary impetigo contagiosa, propagated 
in playing the Rugby game from one boy to another, and also 
from their wearing each other's playing clothes. Cultivations 
by Galloway yielded apparently pure cultures of staphylococcus 
aureus. 

The contagium probably flourishes more easily in the 
cachectic, and the child with a severe attack is generally pale 
and ill-nourished. This may, however, sometimes be the con- 
sequence of absorbing a toxin from the lesions, sufficient, when 
they are numerous, to damage the general health, and even 
produce febrile symptoms. 

Pathology. — The lesions, whether vesicular or pustular, are 
due to the inoculation of pus cocci into the superficial layers of 
the skin, hence no scars are left when the diseased area heals. 

So far all are agreed, but of late years it has been asserted 
that the impetigo contagiosa of Tilbury Fox is always primarily 
vesicular, and due, some say, to the streptococcus, while others 
consider it to be a specific coccus differing from both staphy- 
lococcus aureus and streptococcus pyogenes of Fehleisen; 



IMPETIGO CONTAGIOSA. 



247 



while the primarily pustular follicular impetigo, as described by 
Bockhart, is a separate disease, and is due to the staphy- 
lococcus pyogenes aureus. 

Further, it is generally admitted that in the pustular stage 
of Fox's impetigo, staphylococci are also present in addition 
to the streptococci, but it is said as a secondary invasion. 

There are also the possibilities, viz.: That, as has been proved 
for erysipelas, by Jordan, both streptococci and staphylococci 
may be capable of producing the lesions of impetigo con- 
tagiosa; and, secondly, that these streptococci and staphy- 
lococci are different states of the same organism. 

A short history of the course of events will best show the 
present aspect of the question. 

I was the first to describe organisms in the fluid of unruptured vesicles 
in 1 88 1 * in the form of diplococci and short chains, but no cultures were 
then made. Later cultivations in solid media by various observers gave 
apparently pure cultures of staphylococcus, and three years later Bock- 
hart also found them and considered them to be the streptococcus of 
Fehleisen, the erysipelas microbe, and in his inoculations he produced 
lymphangitis. 

I found chains of micrococci in twos, or multiples of two, which were 
most abundant in the pustules, and were also present at the periphery of 
the epithelial cells, but not in the pus-cells as in Fig. 13. E. A. Barton, 
working in my laboratory, obtained pure cultures of staphylococcus 
pyogenes aureus from the fluid of unruptured vesicles. Inoculation on 
his own arm produced a vesicle, which soon healed. He was prevented 
from pursuing the subject, but Dubreuilh of Bordeaux and others inde- 
pendently came to the same conclusion. 

Unna and Schwenter-Trachsler in 1899 made elaborate researches on 
Fox's impetigo, and also described a specific coccus differing from 
staphylococcus aureus, and in 1900 Sabouraud came to the conclusion 
that Fox's impetigo was due to the streptococcus of Fehleisen, and Bock- 
hart's to the staphylococcus aureus. 

Gilchrist of Baltimore found streptococcus pyogenes to be the agent. 
On the hand other, Charles White of Boston,* in 1899, well aware of these 
researches, ^ still found only staphylococcus aureus as the pathogenetic 
organism, as also did Corlett. Kaufmann in 1899 found in unruptured 
vesicles the same chains and diplococci as I had done, but from his cul- 

* Lancet, 1881, vol. i. p. 82. Fluid was withdrawn in a capillary tube 
from an unruptured vesicle and blown upon a cover glass, dried, and 
stained with methyl violet. The cocci were then readily observed with 
an object glass magnifying 550 diameters. 

f White gave an excellent historical review in a brochure read before 
the Massachusetts Med. Soc, June 13, 1899, with references to date. 



248 DISEASES OF THE SKIN. 

tures concluded that the chains were too short to be the true streptococci 
of Fehleisen; he considered the organism he isolated to be a specific 
coccus, and generally confirmed the view of Unna and Schwenter- 
Trachsler. Matzenauer also isolated a coccus which he was not able to 
differentiate with certainty from staphylococcus aureus. Nabarro,* from 
an unruptured vesicle of a case of my own, obtained a pure culture of 
staphylococcus aureus both in bouillon and gelatin. From these differ- 
ences of opinion it is obvious that further research is still necessary; but 
in order for observations to be of value, only fluid from unruptured vesicles 
must be used, and liquid media employed for cultures, as in solid media 
staphylococcus grows so much more vigorously than the streptococcus 
that the latter is overshadowed, and an apparently pure culture of staphy- 
lococcus aureus nearly always results. To continue to make observations 
on fluid taken from beneath crusts is so obviously open to error as to be 
unscientific and w r aste of time. 

Diagnosis. — The discrete character of the lesions, the absence 
of redness round them, unless they are rubbed, and the inocula- 
bility of the fluid, are the characteristic features. Pustular 
eczema of the face most nearly resembles it, and when the 
lesions of I. contagiosa have coalesced into a patch the re- 
semblance is very close; but discrete lesions are nearly always 
to be found in the neighborhood in I. contagiosa, and the sur- 
rounding inflammation of eczema will give the clew to the diag- 
nosis. It must, however, be borne in mind that sometimes 
the pus of pustular eczema becomes inoculable, and the result 
is a mixed condition. Appropriate treatment for the I. con- 
tagiosa removes it quickly, leaving the eczema uncomplicated. 
The differences between the impetigo of Fox and Bockhart 
have been sufficiently indicated. 

Prognosis. — Under favorable conditions the disease will run 
its course to complete cure in two or three weeks, but is often 
kept up for an indefinite period by auto-inoculation. 

Treatment. — This is simple, and always effectual. Remove 
the crusts by soaking in olive oil until they can be detached by 
the nails or a paper-knife, or by cutting the hair beneath them; 
on the face, bathing with hot water is sufficient to enable the 
crusts to be picked off; then apply continuously an ointment of 
hydrarg. amnion, gr. 10, lard or simple ointment §j, and in a 
few days the sore will heal up completely, and leave only a tran- 
sitory redness. Other remedies will also cure it, but the above 

* Nabarro is the assistant teacher of pathology of University College* 
and has had large experience of bacteriological investigations. 



IMPETIGO CONTAGIOSA. 



249 



obeys completely the motto " Cito, tuto et jucunde," and is 
only contra-indicated when the surface to be dealt with is very 
large, as in I. gyrata of a large part of the trunk. The surface 
may be sponged thoroughly once with 1 in 4000 corrosive sub- 
limate, and then boric acid ointment spread thickly on lint or 
linen and closely applied. 

Ecthyma. Deriv. — e'x6vjua,2L pustule. — This is still consid- 
ered by some dermatologists to be a distinct disease. The 
only cases at all entitled to be so considered, in my opinion, 
are those cases of- inoculated sores seen sometimes in butchers, 
farriers, cooks, etc., from decomposing animal fluids, resulting 
in irregularly outlined, flat pustules on a highly inflamed base, 
generally few in number and in the neighborhood of the pri- 
mary inoculation; but even these are very likely produced by 
the same organism as the ordinary form, which is, I am con- 
vinced, only I. contagiosa of the limbs and trunk, in which a 
more or less red, raised, and even rather hard areola is devel- 
oped by friction, scratching, or other irritation. 

The lesions are invariably secondary either to the ordinary 
form of I. contagiosa, as seen on the face, or to some pruritic 
disease, such as prurigo, scabies, pediculosis, or other parasitic 
irritation, and in children also to urticaria. In short, whatever 
gives rise to scratching is liable to produce in predisposed sub- 
jects the discrete, flat, irregular scabbed pustules, with their sur- 
rounding areola, which characterize the so-called ecthyma, the 
lesions of which on the lower limbs sometimes attain to a large 
size, e. g., an inch or more in diameter, with thick and almost 
rupioid scabs often deep-seated enough to leave scars. 

In every case of this kind, therefore, it is not enough to give 
the eruption a name, but the source of irritation must be care- 
fully inquired for. Sometimes this cannot be discovered, on 
account of the irritant being no longer in operation, the disease 
being kept up by auto-inoculation. 

The pathogenetic organism is the same as that of impetigo 
contagiosa, according to Sabouraud, the streptococcus of 
Fehleisen. 

The lesions can always be healed by the same treatment as 
that for I. contagiosa, but fresh ones may form if the source of 
irritation be not also removed. Since the eruption is most 



25 o DISEASES OF THE SKIN. 

easily excited in delicate children, in the destitute poor, the 
dirty and cachectic, good food and hygiene, cod-liver oil, and 
iron are often desirable adjuncts to the treatment, but not ab- 
solutely essential. 

Pemphigus Neonatorum. — This is not really a separate dis- 
ease, though it is usually so described, but is a bullous infantile 
variant of impetigo contagiosa. 

The eruption begins in the first week or two of life, most 
frequently about the thighs, buttocks, and pubes, but may 
come out on other parts of the trunk and limbs and on the face, 
but, as a rule, the bullae are in small numbers and their develop- 
ment is spread over several days. The bullae rise abruptly 
from the surrounding skin without areola, and have pellucid 
contents, sero-pus or pus being exceptional, and it is only in 
the latter case that there is a narrow red areola. Bullae have 
appeared on the mammae of women who have suckled children 
thus affected. 

If the child is placed in good hygienic conditions, and the 
bullae and flexures are dusted with boric acid one part, zinc 
oxid, pulv. amyli, of each four parts, the bullae present soon dry 
up and fresh ones cease to form, in the great majority of cases; 
but sometimes, especially in epidemics, the infants die, prob- 
ably more from general septic infection, as in Emmett Holt's 
case,* than from the eruption. In Bloch's f epidemic of fif- 
teen cases they all died, and a mixed infection of streptococcus 
pyogenes and staphylococcus was present. When the mother 
has had puerperal fever J with bullous eruption, and the child 
also has pemphigus, it is very likely to die. 

These cases have been called malignant, but there is probably 
no essential difference from the mild form. I have seen a 
hemorrhagic form, in which millet seed to pea-sized mulberry 
red to purple bullae from blood-stained serum began four days 
after birth and continued to come out; they were all over the 

* N. Y. Med. Jour., February 5, 1895, p. "175. 

\Archiv. f. Kinder /teilkunde, xxviii., Bd. I. Abs. in Brit. Jour. 
Derm., vol. xii., 1900, p. 304. 

% Cases are recorded of this by Greer in Brit. Med. Jour., June 6, 1894, 
p. 241. Both mother and child died; Staub of Posen, Ann. de Derm., 
etc., vol. iii., 1892, p. 1200. In one case mother and child recovered; in 
two others the children died and the mothers recovered. 



IMPETIGO CONTAGIOSA. 251 

body, including the palms, soles, and mouth. The child died 
after five weeks. There were empyema infarcts in the spleen 
and small abscesses in the liver; no defect in the hygiene of the 
surroundings was noticed. 

Marcuse * reported a similar case to the Berlin Dermato- 
logical Society. There was extensive denudation of the epi- 
dermis. A case in which the contents of the bullae were bright 
yellow, supposed to be bile, but not tested, was reported by 
Goodwyn f in a child three days old; the eruption got well in a 
week. 

Etiology. — It occurs sporadically in unhealthy dwellings, or 
where there are other children with impetigo contagiosa or 
similar sources of pus cocci contagion; there are also endemic 
outbreaks in certain localities and formerly in lying-in institu- 
tions. 

In one instance which fell under my notice the child was one 
of many who were attacked in the same lying-in institution; 
the disease ran a short and favorable course. 

Some of these local outbreaks have been limited to the prac- 
tice of a certain midwife, and in one such outbreak Bohn 
ascribed it to the midwife putting the child into too hot a bath; 
but it is really of septic origin, and now that asepticism is prac- 
ticed in all lying-in institutions in this country, outbreaks have 
ceased, to occur. In several sporadic cases I have been able to 
prove the existence of defective drains in the house where the 
child was born. Pernet, in investigating some cases in my 
clinic, obtained a history of mammary abscesses in the mothers 
of two cases. In another, on visiting the house, he found three 
other children with impetigo contagiosa. Matzenauer \ relates 
the case of a mother with impetigo contagiosa who infected her 
infant with resulting pemphigus neonatorum, and conversely 
says that when the infantile bullous eruption is communicated 
to adults, impetigo contagiosa results. He also says that, his- 
tologically, the lesion in both is situated between the rete and 
the stratum corneum. Bacteriologically, in both he found on 

* Annates de Derm., vol. x. p. 90; the palms and soles were also 
affected. 

f Brit. Med. Jour., July 21, 1892. 

% Wiener klin. Wochensch., No. 47, November, igoo. p. 1077. On the 
question of identity of pemphigus neonatorum and impetigo contagiosa. 



252 DISEASES OF THE SKIN. 

cultivation a coccus indistinguishable from staphylococcus 
aureus. Brosin and others have also found this organism. 
This point has been investigated repeatedly in cases from my 
clinic for many years, at first with solid and recently with fluid 
media, and a pure cultivation of staphylococcus aureus always 
resulted, while Whitfield obtained a pure cultivation of strep- 
tococcus from one case. This would show that both organisms 
may give rise to these lesions. 

Richter considers that Ritter's dermatitis exfoliativa neona- 
torum is a sub-group of pemphigus neonatorum. When mixed 
infections occur, hemorrhagic bullae, gangrene, febrile symp- 
toms, and death may ensue. Possibly this is the same type as 
that described by Tilbury Fox.* Apparently healthy children 
are seized with severe constitutional symptoms, the skin is livid, 
the areola of the bulla is dark, the contents fetid, the ulceration 
is deep and unhealthy, its surface is dark, blackish, and exudes 
an ichorous matter, the edges being livid and shreddy, so that 
large circular depressed black gangrenous ulcers, acutely pro- 
duced, are present. All parts may be affected and the infants 
die in ten or twelve days. From the context it would almost 
appear that Fox regarded it as a bad form of the disease de- 
scribed by Whitley Stokes under the name of pemphigus gan- 
graenosus, which was probably varicella gangrenosa. See 
Dermatitis Gangrenosa Infantum. 

Diagnosis. — Pemphigus neonatorum must not be confused 
with congenital syphilitic pemphigus. The latter also appears 
in the first week, but the lesions are pustular and attack the 
fingers, especially at the nail matrix, and there are other symp- 
toms with pronounced cachexia, while in P. neonatorum the 
contents are clear, the lesions are large, the hands are seldom 
involved, and the child is often in perfect health. Effectual' 
treatment has been mentioned already. 

Outbreaks of Epidemic Pemphigus, or P. contagiosus, are 
from time to time reported. Some of them are the variety al- 
ready described of P. neonatorum, others are examples of 
varicella bullosa or impetigo contagiosa bullosa, and it is still 
a disputed point whether there is a true pemphigus which may 
be contagious or epidemic. In my opinion they are all bullous 
forms of impetigo contagiosa. 

* Third ed., p. 212. 



IMPETIGO CONTAGIOSA. 253 

These epidemics occur invariably in children. Thus Colrat * 
relates a case of pemphigus in an infant set. eighteen months, 
and a fortnight after its admission four other children in the 
hospital for other ailments developed pemphigus, which ran a 
normal course. The bullae were auto-inoculable, but the new 
one was smaller than the parent bulla. Micrococci like the 
figure 8 were found in the bullae. He carefully excluded vari- 
cella bullosa as an alternative diagnosis, but they were probably 
impetigo contagiosa. 

Dr. Blomfield of Sevenoaks wrote to me in December, 1891, 
informing me that there had been an epidemic in his neighbor- 
hood; ten to fifteen per cent, of the Board-school children had 
had it in the course of the year, whole families having been 
affected. The bullae, up to the size of half a walnut, came out 
on the face, hands, and feet, dried up, and left impetiginous 
sores. 

P. Manson f of Amoy has described a P. contagiosus, which, 
as it is peculiar to the tropics, might be called P. contagiosus 
tropicus. It should be compared with impetigo contagiosa 
gyrata, with which it appears to me to be identical. There is a 
diffuse or infantile and an axillary or adult form, though neither 
form is absolutely limited by age. 

In the diffuse form vesicles or tense bullae up to half an inch 
or more in diameter, with clear contents and without areola, 
appear in crops, with irregular distribution, in any part of the 
body, except the scalp, palms, and soles. The contents soon 
get turbid and the bulla flaccid; it then soon ruptures, but in- 
stead of at once healing up, it spreads at the border with under- 
mined edge to an inch or more in diameter, forming circles 
with pink, perhaps slightly crusted center, or it may heal at one 
side and spread at the other, forming crusted crescents and 
suggesting a syphilid. It is especially liable to attack fat babies 
w T here the adjacent surfaces are in contact, and may then form 
a diffuse raw surface over a considerable area. The disease 
occurs chiefly in hot weather, but may be kept up by auto- 
infection for an indefinite time, and is readily communicated to 
others. Micrococci in groups, or in fours, twos, or singly, 

* Revue de Medecine, December, 1884. 

f Transactions Hong Kong Medical Society, vol. i. (1889), and re- 
print. 



254 DISEASES OF THE SKIN. 

may be easily found by staining with an anilin dye. The 
Chinese did not seem so liable to it as Europeans. 

In the axillary form the disease is limited to the non-hairy 
portions; one or two bullae about one-eighth of an inch are first 
noticed, soon followed by fresh crops, which begin as minute 
red papules with or without a minute vesicle upon them; from 
these, small vesicles up to a buckshot develop, with a slight 
areola; then larger bullae one-fourth to half an inch in diameter, 
which soon get turbid and rupture. The roof of the bulla may 
be left or rubbed off, but the lesion enlarges peripherally with 
its edge undermined to an inch or more; these different ele- 
ments are mixed up in various proportions with others healed, 
or in process of healing. Manson thinks that the longer the 
duration the smaller the lesions. The treatment of both forms 
is simple and effectual. Twice a day the bullae should be 
opened, emptied, and the parts thoroughly sponged with I in 
iooo perchlorid of mercury solution, and then a boracic acid 
dusting powder applied, adjacent surfaces being carefully sepa- 
rated. White precipitate ointment is also effectual, but, espe- 
cially in hot climates, less pleasant than the perchlorid. Care- 
ful consideration of this affection shows a remarkable resem- 
blance to impetigo contagiosa gyrata and impetigo con- 
tagiosa. The high temperature may produce greater activity 
and account for minor differences. A few culture experiments 
would decide the point. 



FURUNCULUS. 

(Latin for boil, diminutive of fur, a thief.) 

Synonyms. — Boil, furuncle; Fr., Furoncle; Gcr., Furunkel, 
Blutgeschwiir. 

Definition. — An acute, circumscribed, phlegmonous inflamma- 
tion round a skin-gland or follicle, resulting in its necrosis and 
suppuration. 

Symptoms. — In this familiar affection the lesion may be 
single or multiple, in the latter case, coming in crops of from 
two to half a dozen or so, and no sooner have these got well 
than a fresh crop appears, and keeps up the process of what is 



FURUNCULUS. 255 

termed " furunculosis," for weeks, months, or years, if un- 
treated. The boils do not form any definite group, but are iso- 
lated and scattered over the same, or widely separated regions. 

Each boil begins as a painful induration in the skin, soon 
followed by a red spot or pit, which feels like a firm disc or 
shot-like body embedded in the corium. As it enlarges, it be- 
comes raised above the surface, and gradually forms a convex 
swelling, with a tendency to point, and when fully developed is 
from a small split pea to half a plum in size, of a deep red, with 
or without a yellow center, while at the periphery the color is 
brighter, with red areola. The center softens, gives way, and 
from the opening, pus, and a piece of whitish, pultaceous, 
necrotic tissue called a " core," are discharged, though not in- 
frequently this core may require a day or two longer for com- 
plete separation. Up to the time of evacuation there is a burn- 
ing and throbbing pain, especially at night, quite out of propor- 
tion to the size of the boil, while the tenderness is so great as 
to be proverbial. All this is relieved at once by the discharge; 
the indurated, infiltrated tissue gradually softens, and is ab- 
sorbed; the swelling subsides; the redness fades; the cavity 
fills up by granulation, and leaves more or less of a scar. Or 
the tumor may stop short of suppuration and resolve, consti- 
tuting what is popularly known as a " blind boil." Constitu- 
tional disturbance is often present in proportion to the num- 
ber and size of the boils, and the lymphatics and glands in the 
neighborhood are liable to sympathetic inflammation, going 
on sometimes even to suppuration. 

Such is the history of furuncular inflammation in a sebaceous 
gland or hair follicle; and, while no part of the body is exempt, 
boils occur chiefly in the neck, face, forearms, buttocks, and 
legs. 

According to Sabouraud, Bockart's impetigo is always the 
precursor of furunculosis, but this is too sweeping an asser- 
tion. Superficial pustules often precede, and are constant con- 
comitants of crops of boils, but boils may develop without such 
antecedents. 

Variation. — When the furunculus begins in the sweat coil, it 
constitutes what Verneuil described as hydrosadenitis phleg- 
monosa. Contrary to the view put forward in the second edi- 
tion of this work, I now consider Verneuil's hydrosadenitis dif- 



256 DISEASES OF THE SKIN. 

ferent to that of Pollitzer, which is described with acne agmi- 
nata, which is the same as the acnitis of Barthelemy. 

It is most frequent in the axillae and fork, and all about the. 
genito-anal region, near the nipples, the arms, and sometimes 
the face and neck, and may form wherever there are sweat 
glands, except on the soles. It is very like the ordinary form 
of boil, and, like it, there may be only one or two, or a crop. 
But at first it is subcutaneous, and only involves the skin as it 
nears the surface; it has no mattery head, and there is less in- 
duration and not much pain. It is ascribed to local irrita- 
tion, but in my experience is connected with hyperidrosis. 
It is said to be more common in young people, but in two 
of my patients it came on at the climacteric. A lady * of sixty- 
five, whom I saw with Dr. Duncan Greig, had been subject for 
twenty years, dating from her climacteric, to suppurating 
lesions like boils, but without the induration of ordinary boils. 
They occurred symmetrically in the axillae, the cleft of the anus 
and fork, but not in front, and to a slight extent in the bend of 
the elbow, at the root of the neck, and between the breasts. 
When one came on one side, before long another matched it on 
the other. In all the regions affected there was pigmentation 
of a lentiginous character, numerous sinuses, and considerable 
scarring. When I saw her she had only one recent, superfi- 
cial, inflamed, and boggy tumor the size of a split pea, without 
induration, and a puncture gave exit to a little sanious pus. 
There were older soft swellings about the gluteal cleft, which 
also contained pus. The recent ones were tender, the older 
were not. She sweated profusely. There was no organic dis- 
ease, but she took no exercise. 

Etiology. — Ordinary boils, when single, are usually dependent 
on local injury, such as blows, friction, or pressure, c. g., on 
the buttocks of oarsmen, in prolonged decubitus from any 
cause, etc. When in successive crops, they are often predis- 
posed to, at least indirectly, by vitally depressing influences, 
sometimes of a septic character. Thus they occur in diabetes 
mellitus, after various specific fevers, especially variola, and in 
anemic, lithemic, uremic, and septicemic states. Of external 
causes, sewer-gas poisoning is the most potent. There is, how- 
ever, strong reason to believe, as will be seen in discussing the 
*Mrs. C. Private notes, E., p. 130. 



FURUNCULUS. 257 

pathology, that the above conditions merely offer a favorable 
opportunity for the development of the matcrics morbi. In not 
a few instances no defect of health can be detected, and there 
is a popular notion that too good living is responsible. The 
late Mr. Startin proved that they were auto-inoculable by 
scratching; that the pus was inoculable, e. g., by a contaminated 
lancet, boils occurring at the seat of puncture; and that even 
prolonged contact, as by the occupation of the same bed, was 
sufficient for their conveyance. 

Boils are a common complication in pruritic eruptions, such 
as eczema, prurigo, scabies, etc. 

Pathology. — According to Kochmann, boils always begin 
round the hair follicles or the glands, but to these Verneuil has 
shown we must add the sweat glands, and it is now established 
that the inflammation is set up by microbes which gain entrance 
through these channels. According to Pasteur, whose obser- 
vations have been confirmed by Loewenberg, Gilchrist,* and 
others, micrococci, which are now known to be chiefly, if not 
entirely, staphylococcus aureus, less frequently albus and 
citreus, can always be found in the contents of boils, and 
cultures from this are inoculable; but abscesses, not furuncles, 
are produced in animals. Guigeot accounts for this by the 
culture being introduced into the cellular tissue, instead of 
limiting the inoculation to the sweat ducts or follicular orifices. 
Loewenberg suggests that when once a boil has formed, the 
microbes may be transferred by auto-inoculation, and also that 
they may get into the circulation and that the crops of boils are 
kept up in this way; but if this is so, it is strange that the 
process should always be limited to the skin glands and fol- 
licles. In order that these organisms should flourish, it is ad- 
mitted that the soil must be suitable, c. g., that there should be 
a predisposition on the part of the patient, and this is found in 
the various debilitating influences mentioned under Etiology. 
The mechanism of the process is supposed by some to be that 
the vessels round the gland or follicle become blocked, produc- 
ing its death, and inflammation is then set up round the 
necrosed tissue to get rid of it by suppuration. In aural 

*Vol. xiv., John Hopkins Hospital Reports. Gilchrist examined 
twenty case.s at all stages, and invariably found in pure culture staphylo- 
coccus aureus. They were present as diplococci in the pus. 

17 



258 DISEASES OF THE SKIN. 

furuncles * the organism most frequently found was staphy- 
lococcus albus, next to this S. aureus, and sometimes S. citreus. 
Kirchner of Wurzburg found S. albus only. These organisms 
have not yet been demonstrated in sweat boils. 

Diagnosis. — The disease is so well known that the patient 
usually makes the diagnosis himself. The peculiarities of 
sweat boils have been already pointed out. The differences 
from a carbuncle are given with that disease. 

Prognosis. — When occurring in crops the disease often gives 
much trouble, but perseverance in the method to be mentioned 
will be rewarded with success, though it is impossible to predict 
how long it will last. When dependent upon some serious 
general condition boils are often numerous, and aggravate the 
depression of health already present by the suffering and worry 
they occasion. 

Treatment. — The first thing is to investigate the general con- 
dition of the patient, examine the urine both for albumin and 
sugar, and see if there is any defect in the health, habits, and 
surroundings which will account for the disease. Among 
these defects drainage and water supply are to be specially 
looked into, and in such cases, and in many others, change of 
air is often necessary. Unless the patient is gouty, tonics and 
nutritious diet are generally indicated, and ferruginous 
aperients (Mixtures, F. 16), are adapted to a large number of 
cases. Although the following internal remedies are to a cer- 
tain extent useful, early local disinfection is the most efficient 
means of preventing constant recurrence, and if the circum- 
stances of the patient allow of its being efficiently carried out, 
the boils will soon cease to form. 

Supposing every attention has been paid to the general 
health, one or other of the following remedies has frequently 
been successful in my hands, viz.,* fresh yeast, half a wineglass- 
ful to be taken night and morning, or a less quantity more fre- 
quently. This is a popular and good remedy, though its modus 

* Loewenberg, Internat. Med. Cong., 1887. 

f Brocq, evidently unaware of its being so well known and used in Eng- 
land, rediscovered it in 1894 as a cure for boils and strongly advocates its 
use. He says that no publication between 1852 and 1894 occurs about it, 
whereas it is mentioned in the above terms in my first edition in 1888, and 
was then " as old as the hills." 



FURUNCULUS. 259 

operandi is not clear, unless we suppose that the yeast organism 
has the power of appropriating some pabulum necessary for 
the existence of the furuncle organism. Another remedy is 
that proposed by Ringer: one-tenth of a grain of sulphid of 
calcium every two or three hours, or one-fourth of a grain three 
or four times a day. As the sulphid speedily decomposes and 
becomes inert on exposure to the air, it should be prescribed in 
coated pilules. In cases due to sewer-gas poisoning large 
doses of quinine are requisite. 

Locally. — Every boil is a fresh nidus for the cultivation, and 
a center for the subsequent dissemination, of the cocci which 
produce the lesion; if, therefore, the cocci in each boil are de- 
stroyed as soon as possible, the supply will thus be exhausted, 
and fresh boils soon cease to appear. 

Both theory and practice forbid the time-honored plan of 
poulticing, and all hot wet dressings, unless antiseptic, are 
equally calculated to favor the development of further boils. 
After disinfecting the cavity, ten grains of iodoform to §j of 
boric acid ointment is a good dressing to a freely discharging 
boil, the cavity being daily syringed out with the carbolic solu- 
tion. The treatment I adopt is to open each boil as soon as 
there is softening of the center, syringe it out with I in 40 car- 
bolic acid, and put in the strong liquid or the crystals into the 
cavity. 

The boils should not be opened in the hard stage, and when 
they are discharging they should not be squeezed. A small 
boil roughly handled is easily converted into a large one. 

To abort them, an almost certain plan is to inject beneath 
the boil five drops of a 1 in 30 solution of carbolic acid. 

Guigeot strongly recommends that spirit of camphor should 
be applied for a few minutes at a time, by means of a compress 
dipped in it three or four times a day: or tincture of iodin 
painted on freely three or four times a day, over and beyond the 
furuncle, until desquamation occurs. Loewenberg recom- 
mends a saturated solution of boric acid; this plan is a good 
one, and even when it does not stop it will limit the amount of 
suppuration. Other means to abort boils are caustics, nitrate 
of silver, nitrate of mercury, strong carbolic acid, and nitric 
acid painted on. 

For sweat-gland boils painting with collodion is simple and 



2 6o DISEASES OF THE SKIN. 

effectual for slight cases. Disinfection in the same way as 
ordinary boils is often necessary, and the hyperidrosis should 
be treated (see that disease). In the case of the lady with the 
sweat boils previously described I got Dr. Greig to open up 
the sinuses and thoroughly disinfect them, and every fresh boil 
as soon as possible, and in three months she was completely 
cured of the affection which had gone on for nine years. 



CARBUNCULUS. 

(Dimin. of carbo, a live coal.) 

Synonyms. — Anthrax,* Carbuncle; Fr., Anthrax; Ger., 
Carbunkel, Brandschwar. 

Definition. — An acute phlegmonous inflammation, circum- 
scribed but more extensive than the furunculus, terminating in 
a more or less extensive sloughing of the tissues, and gangrene 
of the superjacent skin. 

Symptoms. — The carbuncle is allied to, but is a much more 
serious affair than the boil, and when extensive, or in elderly or 
cachectic subjects, may have a fatal termination. Unlike the 
boil it is usually single, and favors the extensor aspects, espe- 
cially the neck, shoulders, back, buttocks, and forearms. 

A firm, flattish, inflammatory infiltration forms in the sub- 
cutaneous tissue or deep part of the corium, and extends ver- 
tically and laterally; the surface is of a bright red, soon get- 
ting deeper-tinted, and there are pain and burning from the 
first. In ten days to a fortnight it is fully developed, and then 
consists of a deeply seated, flatly convex tumor or circum- 
scribed infiltration of a deep and livid red color and with a 
hard, characteristically brawny base, gradually merging into 
the surrounding tissues. Softening of the center of the mass 
and of the skin soon takes place, but there is no pointing, the 

* It is, I think, preferable to employ the term carbunculus instead of the 
more common one of anthrax, as that term is ambiguously used, some- 
times meaning the affection under consideration, at others malignant 
pustule or the local manifestation of splenic fever, but the well-known 
name bacillus anthracis is exclusively applied to the splenic fever 
organism. 



CARBUNCULUS. 261 

skin being covered with pustules, and simultaneously giving 
way at. several points, forming numerous cribriform perfora- 
tions, through which sanious pus exudes. And the slough is 
visible and is slowly separated, either entire or in parts, and 
gradually comes away through the enlarged openings, leaving 
a deeply and irregularly excavated ulcer, with firm, sharply cut, 
everted edges; the cavity fills up with new granulation tissue, 
and forms a cicatrix, often pigmented, and perhaps puckered, 
but smaller than might be expected from the size of the origi- 
nal sore. 

Variations. — Sometimes, when at its acme, the skin over it 
becomes bluish-black and gangrenous, a blood-filled bleb is 
formed, or the whole skin breaks down into a dirty, pulpy 
mass; or instead of moist, there is dry gangrene, the whole of 
the dead tissue drying into a hard brown or black eschar, 
which separates in the usual way. Or, again, the process may 
extend, the central changes being repeated at the periphery, 
with copious and exhausting suppuration. The general dis- 
turbance is considerable. Rigors, elevation of temperature, 
general aching, and other febrile symptoms, varying according 
to the extent of the lesion, are present in all but the smallest 
carbuncles. Where there is extensive sloughing septic fever 
is often developed. The duration is then from two to six 
weeks, according to the age and vital powers of the patient and 
the size of the carbuncle, w T hich may be as large as a soup plate; 
the most common size, however, is from one to three inches. 

Etiology. — It occurs more often in men than women, and in 
middle and old age. It is most common in those who are suf- 
fering from constitutional depression from causes similar to 
those of furunculosis. It is a not unusual complication of 
diabetes, and its favorite positions suggest that its site is often 
determined by a local injury from pressure or otherwise, but 
this has not been definitely proved. 

Pathology. — The generally received view is that the process is 
clearly analogous to that of the furunculus, due to the same 
staphylococci, but the process lies deeper. Though, like the 
furunculus, it is said to begin in the sebaceous and sweat glands 
and hair-follicles, it goes down into and travels along the 
planes of the subcutaneous tissue, as it has not the lateral limi- 
tations of the boil, but vertically is bounded by the fascia. 



262 DISEASES OF THE SKIN. 

Collins Warren * of Harvard University, however, explains 
it as follows: The process begins in foci of inflammatory cells 
in the subcutaneous tissue; these coalesce and extend up the 
columnae adiposes, which swell, elongate, and disintegrate, the 
cells eventually reaching the surface and forming a pustule 
round the hair-follicle ; laterally, the inflammation spreads along 
the lymph channels and vessels that branch off from these fat 
columns, so that the whole mass of the corium becomes in- 
volved in the destructive inflammation, except a thin super- 
ficial layer which lacks the channels present so abundantly be- 
low. Those of the pustular points visible on the surface which 
are not seated at the hair follicle are collections of wandering 
cells, dilating the papillae into peg-top-shaped cavities, and 
thinning the rete over them until it gives way. The same 
process extending subcutaneously, the infiltration becomes so 
dense that the blood-vessels are pressed upon, and all the 
tissues break down except the more persistent fibrous bands 
which bind down the integument in the back, and which remain 
at the bottom of the cavity and form the well-known tough, 
adherent sloughs. 

Thus, in Warren's view, a carbuncle is primarily a suppura- 
tion in the subcutaneous tissue, and secondarily infiltrates 
the corium by channels which only exist where it is thick, 
and where there are rudimentary or lanugo hair follicles, 
which do not reach down to the fat. In parts where the skin 
is thin these columns do not exist; the cribiform appear- 
ance is not developed, the pus oozing out at one or more less 
resisting spots, traveling along a lymph space to reach the 
papillae. 

While pus organisms were not known to Warren as the pri- 
mary cause, his explanation of the subsequent mechanism of 
the process is not invalidated. 

Diagnosis. — The carbuncle is distinguished from the furuncle 
by its much greater size, its flatter shape, its brawny border, 
and, when it is breaking down, by the multiple instead of the 
single opening and the complete destruction of the skin over the 
sloughy tissue beneath; from more diffuse phlegmonous inflam- 

*" Columnae Adiposse, with their Pathological Significance in Carbun- 
cles and Other Affections." A small monograph. (Cambridge, U. S., 
1881.) 



* CARBUNCULUS. 263 

motions, by its circumscribed brawny border, the greater pain- 
fulness, and the cribiform perforations. 

Prognosis. — This depends upon the age and general health of 
the patient and the size and course of the carbuncle. As at the 
commencement it is impossible to predict the size and course, 
the prognosis must be guarded; especially must this be the case 
in old people and those broken down by disease, e. g., diabetes. 
Those on or near the head and face are considered to be more 
serious than the others. 

Treatment. — As in furunculosis, careful investigation into the 
patient's general health, especially as regards diabetes, is an 
important preliminary, and a supporting treatment is generally 
advisable from the first. Alcohol in any form, however, is bet- 
ter avoided, at all events until the contents of the carbuncle 
have been evacuated, as it is liable to increase the tension, and 
therefore the pain of the inflammatory swelling. When, how- 
ever, it is opened, and there is free suppuration, alcohol, pref- 
erably, as a rule, in the form of port or burgundy, may be re- 
quired. Perchlorid of iron in full doses (5ss of the tincture or 
liquor every four hours) is often very valuable, and where there 
are any signs of septicemia, quinine in full doses (gr. 5 or even 
gr. 10 of the hydrochlorate every four hours) often acts most 
effectually. Care must be taken to obtain sleep, if necessary 
by anodynes, hypodermic injections of morphia (1-6 to 1-4 gr.) 
being one of the best forms. Chloral hydrate is indicated only 
when the pain is moderate. Every possible means must be 
adopted to improve the general condition and surroundings. 

Locally, the old classical treatment of linseed poultices and 
crucial incisions is abandoned by general consent, and boils are 
likely to be excited in the neighborhood of the carbuncle by 
poulticing. The only applications of this class at all permis- 
sible are boric acid lint wrung out in hot water, or compresses 
formed of pads of Gamgee tissue wet with hot carbolic solu- 
tion 1 in 40 and covered with oiled silk. 

If the carbuncle is seen in an early or spreading stage a solu- 
tion of carbolic acid 1 in 30 should be injected subcutaneously 
all round the carbuncle. This, if done thoroughly, almost in- 
variably stops the extension. Hot compresses of carbolic 
solution may also be applied over it. As soon as there is soft- 
ening the purulent contents should be evacuated, the cavities 



264 DISEASES OF THE SKIN. 

thoroughly syringed out as far as possible with carbolic lotion 
1 in 40 and crystals of carbolic acid pushed into all the open- 
ings. Sloughs as they become loosened should be removed as 
soon as possible, and it has been recommended not to wait for 
loosening, but to scoop them out with a sharp spoon or cut 
away as much as possible. This is the best plan for small 
sloughs, but with large ones may be attended with serious 
bleeding not easily controlled, and in these it is best to keep on 
introducing strong carbolic acid until the septic process has ter- 
minated. Rushton Parker recommended early excision of the 
whole lesion, but few patients will consent at this stage to an 
operation of this kind. Mercurial plasters, such as No. 88 
Beiersdorf, assist in removing the brawny induration. 

HERPES. 

Deriv. — epnrjs, a creeping. 

The meaning of this term has much changed. As its deriva- 
tion indicates, it was originally applied to creeping eruptions, 
but not always of the same kind; thus one set of authors applied 
it to spreading surface eruptions, as ringworm, or herpes circi- 
natus et tonsurans, terms still in use in this sense in some parts 
of the Continent. Others used it to designate lupus exedens 
and spreading cancer, but this use for it is quite obsolete. 
Many older French writers, such as Bazin,* or Gigot-Suard,f 
considered a great number of eruptions of various kinds to be 
due to a diathesis which they call " Herpetisme " and formed 
such eruptions into the class " Herpetides "; as these views no 
longer meet with acceptance even in France, they need no 
further consideration. 

In the modern and general acceptation of the term, herpetic 
eruptions are characterized by the presence of one or more 
groups of vesicles on an erythematous base. Even this clinical 

*Bazin's "Affections cutanees, arthritiques et dartreuses," 2d ed. 
(Paris, 1868). 

f " L'Herpetisme, Pathogenie, Manifestations, Traitement, etc." (Paris, 
Bailliere et Fils, 1870.) Also Lancereaux, " Traite de L'Herpetisme" 
(Paris, 1883); and Besnier's critique on it, Ann. de Derm, et de Syph. y 
vol. v. (1884), p. 530. 



HERPES ZOSTER. 265 

definition includes eruptions of very different pathology, such 
as herpes iris, whose relations are with exudative erythema, 
under which it is described; and dermatitis herpetiformis, which 
is sometimes called herpes gestationis. 

In this work three diseases only are classed under herpes: 

Herpes Zoster; 

Herpes Febrilis (Facialis or Labialis); 

Herpes Progexitalis or Preputialis. 
They are all admittedly of neurotic origin, but while in H. 
zoster the groups are multiple, and follow the course of the 
cutaneous branches of a nerve ganglion, and as a rule the 
patient is attacked only once, in the other two recurrence is 
the rule, no nerve distribution can be made out, and there is 
often only one group. 



HERPES ZOSTER.* 

Synonyms. — Shingles; Zona; Zoster; Ignis sacer; Fr., Zona; 
Gcr., Feuergiirtel, Giirtelausschlag, Blaschenflechte. 

Definition. — An acute inflammatory eruption, consisting of 
groups of vesicles on an erythematous base, distributed in the 
course of the nerve fibers in the domain of one or two posterior 
root ganglia. 

H. zoster is a more common disease than is shown by der- 
matological statistics; my own give 6 per 1000. H. Head at the 
London Hospital found it to be 1 in 418 medical cases of all 
kinds. The discrepancy is explained by its being an easily 
recognized disease which runs a short course, and therefore sel- 
dom finds its way to a dermatologist. 

Although many qualifying terms have been employed to 

* Literature.— Author's Atlas, Plates XV. and XVI., shows zoster of 
the trunk and limbs, of different degrees of seventy, and of the ophthalmic 
division of the fifth nerve. Of the latter also an excellent plate is No. VIII. 
of the Sydenham Society's Atlas. Kaposi's Hand Atlas, Plate CII., shows 
severe attack affecting first and second divisions of fifth, and Plate XCIII. 
bilateral herpes of two divisions of fifth. Dr. Sykes of Exeter points out 
that Zoster is derived from the Roman " Zooster," which consisted of a 
bronze portion with studs, which reached half round the body, the girdle 
being completed with leather. 



266 DISEASES OF THE SKIN. 

designate the locality of the eruption, there is only one kind of 
zoster, as far as the eruption is concerned, but the nerve lesion, 
of which it is the immediate outcome, may be idiopathic or 
secondary to previous disease. 

Symptoms. — The idiopathic form is by far the most common, 
and is in some cases preceded by prodromal febrile symptoms 
of an indefinite character and uncertain duration, but commonly 
all that is observed is slight or severe neuralgia, in the lines of 
the ensuing eruption, usually preceding the eruption by a few 
hours to several days, generally, but not always, relieved on the 
appearance of the eruption, which is, however, attended with 
tingling and smarting. The eruption commences with the for- 
mation of groups of closely set acuminate papules, which 
speedily become vesicles, irregularly arranged on an erythema- 
tous base. 

Distribution. — In a previous edition of this work it was 
pointed out that the eruption did not correspond with a single 
nerve area on the trunk, but that fibers of more than one nerve 
probably passed through a single nerve ganglion, and hence 
widened the area of the eruption. To Head, however, belongs 
the credit of having conceived the idea of utilizing zoster to find 
out the posterior root zones, and he with infinite pains observed 
the distribution of over four hundred cases of zoster, and from 
these mapped out approximately the areas under the domain of 
the different posterior root ganglia, and the diagrams thus con- 
structed he has kindly allowed me to reproduce. Various cir- 
cumstances, as Head points out, modify the position of the 
vesicular groups in different cases. Thus, on the one hand, 
only part of a ganglionic area may be attacked, and on the 
other, more than one ganglion may be involved, and two root 
areas comprehended in the eruption; this is especially likely to 
occur in the ganglia of cervical 2 and 3 or 3 and 4. The ap- 
parent position of the eruptive groups would be different in a 
barrel-shaped chest as compared to a long narrow one, the 
nipples and umbilicus being the only safe landmarks. 

The nerve fibers of adjacent nerves may be differently dis- 
tributed in the ganglia in different cases, and their peripheral 
extension may vary; thus they may extend over the middle line 
or to varying distances along the limbs. 

The main point to be borne in mind is that distribution is 




Fig. 16.*— Diagram, according to H. Head, to show the areas occupied by 
the eruption of Herpes Zoster (front view). 

* Copied by permission from "The Pathology of Herpes Zoster," by 
Henry Head and A. W. Campbell. From Brain, autumn part, 1900. 
Reprint by John Bale & Co., London. 



2 68 DISEASES OF THE SKIN. 

governed by posterior root ganglia zones, and not by single 
nerve areas. 

The typical form which gave rise to the distinctive names 
which signify a " girdle " affects, therefore, the domain of a 
posterior root ganglion of one of the dorsal nerves, hence the 
eruptive groups are nearly horizontal on the thorax instead of 
following the slope of the ribs, as a single intercostal nerve does. 

The eruption is unilateral; the groups come out successively, 
the first formed being nearest the nerve center as a rule; and 
the eruption, as a whole, occupies from three days to a week 
before it is completely developed. The groups often corre- 
spond with the position where the cutaneous branches pierce 
the fascia or are distributed in the skin, and there is often ten- 
derness, as Parrot pointed out, in these positions. 

In an intercostal herpes one group is situated near the spine, 
another in the axillary region, and a third close to the median 
line anteriorly, but sometimes a group fails to be developed or 
remains papular, or there may be more than one group in each 
region, but the half-girdle is seldom continuous. The vesicles 
vary in size from a pin's head to a pea, or larger when con- 
fluent, and in number from half a dozen to a score in each 
group. The contents are at first clear, but soon become turbid, 
and in a simple case soon dry up into scabs, which fall off in a 
few days, leaving red marks which take somewhat longer to 
disappear. The whole process, up to the falling off of the 
scabs, lasts from ten days to three weeks. 

Variations. — In a few cases the prodromal febrile symptoms 
are very decided, but not distinctive, their meaning being un- 
intelligible until the eruption appears. In many cases, on the 
other hand, the eruption is the first sign of the disease. 

H. zoster is by no means confined to the trunk, as Willan 
thought, calling the eruption when occurring elsewhere H. 
Phlyctenodes, though the trunk, especially on the right side, 
is more often affected than all the other regions added together. 
It may attack the domain of almost any nerve, though it has 
preferences. On the head the Gasserian ganglion is involved, 
and areas corresponding to branches of the fifth are frequently 
affected, especially the supra-orbital, and in this case the erup- 
tion extends on to the scalp, as it also does when the occipital 
nerve is attacked. 




Fig. 17.— Zoster areas, after H. Head (back view). 



270 



DISEASES OF THE SKIN. 



Sensory areas of the neck, arm, less frequently the forearm 
and hand, the buttock, genitals, thighs, and other regions, are 
from time to time affected, and sometimes it may be two neigh- 
boring regions, such as the neck and arm, trunk and arm, 
genitals and thigh, etc., but it is rare for it to attack two dis- 
tant regions such as the forehead and trunk, on the same or 
opposite sides as in Hutchinson's and Bradshaw's cases.* It 
is rare below the knee and very rare on the foot, except when it 
affects the line of the saphenous nerve, when there may be 
vesicles on the heel. 

Names have been given to designate herpes of these regions, 
and so authors speak of H. frontalis, ophthalmicus, cervicalis, 
brachialis, cruralis, genitalis, cervico-brachialis, intercosto- 
humeralis, genito-cruralis, and so forth. The only difference 
is in the positions, but of course the eruptive groups are in 
lines, not in zones, since they follow the nerve ganglia distribu- 
tion. Head f contends that zoster or zona should always be 
affixed to distinguish it from herpes febrilis. 

* Lancet, October 13, 1894, p. 851. 

f K. Head carefully noted the distribution of 36 cases of zoster, 
which he collected in different parts of University College Hospital. 
These he was kind enough to place at my disposal, and adding them 
to 64 of my own, the result of the hundred cases was as follows: 
Trunk, 54 cases; ilio-inguinal, ilio-hypogastric, and genito-crural, 13; 
cervical, 13; fifth nerve, 8; leg. 8; arm, 3 — febrile herpes was not 
included. In his monograph he gives the following distribution of 414 
cases according to the ganglia affected. 



Trigeminal 




5th Dorsal 








38 


1st Division 


. 18 


6th 








20 


2d 


2 


7th 








19 


3d " . . . 


2 


8th 
9th 








36 
19 


Total Gasserian ganglion 22 


10th 








26 


2d Cervical . 


T 


nth 








22 


3d " . . . 


• 15 


1 2th 








18 


4th 


. 21 


1 st Lumbar 








27 


5th " . 


2 


2d 








22 


6th 


• 3 


3d 








5 


7th " . . 


. 5 


4th 








1 


8th 





5th 








2 


1st Dorsal . 


• 5 


1st Sacral 











2d 


'• 9 


2d 








1 


3d " . . 


• 34 


3d 








5 


4th 


. 38 













He infers from this table that the ganglia most commonly affected are 



HERPES ZOSTER. 271 

Herpes is very rarely symmetrical,* and then is said to be 
generally of syphilitic origin, and chiefly affects the fifth pair, f 
Jamieson \ of Victoria records a case of a woman who four 
days after severe headache and vomiting had also shooting 
pains in chest and shoulders, and a symmetrical zoster faciei, 
nuchae et brachialis. G. Carpenter § also records a case of a 
child of four with double zoster at the same level. It must be 
remembered that some cases of extensive H. febrilis of the face 
are easily mistaken for double zoster. || It may occasionally 
be bilateral, affecting nerves at a different level, and it is com- 
mon for some of the vesicles to overstep the middle line, doubt- 
less because a cutaneous nerve twig has extended farther than 
usual. Hemorrhage sometimes occurs into the vesicles, or the 
inflammation may be so intense as to be purulent from the first, 
and in rare instances the patches may ulcerate, or even become 
gangrenous. Scarring, of course, then ensues, and keloid may 
follow. Zoster, as a rule, does not attack the same person 
more than once in his lifetime, but there are exceptions; one of 
the most notable was Kaposi's case.^j Within a short space of 
time there were five attacks in the right cervico-brachial 
region, later on a sixth attack in the right lumbo-sacro-crural 
region, whilst the seventh, eighth, and ninth outbreaks were in 
the left cervico-brachial region, and there have been two abor- 
tive attacks since. 

Tilbury Fox had a patient who had several attacks in the 

those which receive afferent impulses from the viscera, through the white 
ramus of the sympathetic. He also says that the ganglion cells are in two 
groups of large and small cells, and that the ganglia in which the small 
cells preponderate are the most frequently attacked. One of the 
functions of these cells is the perception of pain, and he thus explains 
the frequent severe pain of zoster, but he does not account for its frequent 
absence. 

* Hence the popular idea, as old as Pliny the Elder, that if it encircles it 
kills. 

f A case of this kind is figured in Hebra's Atlas, vol. ii., Lief, vi., Tafel 
ix. 

% Australian Med. Jour., May, 1877. 

§ Brit. Jour. Derm., vol. iv. (1892), p. 23, with reference to other cases. 

|| Testut (toe. cit.), p. 74, collected thirteen cases of double zoster, but 
some were certainly H. febrilis. 

■" Abstract from Wiener med. Wochenschrtft, 1874, 1875, and 1877, i n 
Med. Rec, November 15, 1877. 



272 DISEASES OF THE SKIN. 

course of a few years, and always in the summer. Chronic 
peripheral irritation is the most usual cause of such repetitions. 
Thus I have seen recurrent herpes round the sinus produced 
by a diseased tooth. Pearce Gould had a similar case from 
caries of a rib, etc. Pernet reports a case with four attacks, 
one intercostal, the other three on the right side of the neck, 
and he suggests that an uncorrected error of refraction was the 
cause. 

Grindon * collected sixty-one cases of recurrent zoster. 

Complications. — Iritis and more or less severe conjunctivitis 
is apt to accompany herpes of the ophthalmic division of the 
fifth, especially, but not exclusively, when the nasal branch is 
affected, and in one case hypopion keratitis occurred (Flem- 
ming), and in another retinal hemorrhages. Severe scarring is 
also a frequent sequel to this form of herpes. When the second 
branch of the fifth is involved patches of herpes may also de- 
velop on the buccal mucosa, palate, tonsil, and tongue on the 
same side, and Stephen Mackenzie once found at a post-mortem 
herpes in the pharynx and esophagus. The teeth on the 
affected side sometimes fall out, and even necrosis followed in 
Paget's case.f True pharyngeal zona is unilateral and seldom 
recurs. Most of the bilateral pharyngeal herpes are frequently 
recurrent, and are really herpes febrilis. 

Occasionally the function of the neighboring motor nerve \ 
has been interfered with, this being most frequent in facial H. 
zoster, where paralysis of the third or seventh sometimes en- 
sues. Vernon, Broadbent, Waren Tay, and Voigt have also 
reported a similar association. Howard relates a case of 
ophthalmic herpes with iritis followed by ptosis; and Silcock 
has had two cases of complete ophthalmoplegia, externa and 
interna, following H. ophthalmicus. Paralysis of the seventh 
is especially liable to occur when the zoster affects the occipi- 

* Amer. Jour. Cut. and Gen.-Urin. Bis., vol. xiii. (1895), pp. 191 and 
252. Some r>ther cases in annotation of Lancet, April 12, 1902, p. 1050. 

\ Brit Med. Jour., vol. ii. (1866), p. 402. 

\Brzt. Med. Jour., August 6, 1870. Waller of Amsterdam, quoted in 
Brit. Med. Jour., September 19, 1885, relates two cases, one of paralysis 
of the seventh and another of that supplying the deltoid, following zoster 
of those regions. Both recovered under electricity. Other cases are on 
record. 



HERPES ZOSTER. 273 

tal region or front of the neck, i. c, second cervical. Eichhorst 
collected eighteen cases (Head). There is loss of faradic ex- 
citability of the facial muscles. Besnier relates the case of a, 
student who, while studying a case of ophthalmic herpes, was 
himself attacked, and permanent facial paralysis ensued. Head 
saw a case where zoster over the first dorsal area was accom- 
panied by paralysis of all movements of the hand and fingers.* 
J. Duncan f records two cases of old women in whom H. zoster 
was accompanied by hemiplegia of short duration, and prob- 
ably, therefore, of vaso-motor origin. Weiss reports a sym- 
metrical zoster affecting branches of the median, recurring at 
intervals and producing trophic disturbances of the skin and 
nails supplied by the median nerve, and " thumb clonus," i. c, 
a tremor, lasting a quarter of a minute, excited by sharp flexion 
of the palm, and ceasing with extension of it. 

Although the neuralgic pain usually subsides when the erup- 
tion is out, and may even be absent altogether, sometimes, 
owing to a chronic neuritis having been set up, the pain per- 
sists, and in old people, in whom it is specially liable to occur, 
becomes of serious moment from exhaustion consequent upon 
the pain and loss of rest. 

In a few cases persistent pruritus, hyperesthesia or anes- 
thesia, and in a case of Schwimmer's white patches, were left 
in the area of the affected nerve; and Barthelemy and others 
have noted cases of pre-eruptive or simultaneous enlargement 
of the glands in the neighborhood of the zoster, and argue from 
this against the primary nerve origin of the disease. 

Tenneson, Jeanselme, and Leredde draw attention to the oc- 
currence of " aberrant vesicles " scattered about at a distance 
from the principal groups, but generally on the same side of the 
trunk. Fere and Girandeau have also recorded cases, and the 
occurrence of these vesicles is used as an argument in favor of 
zoster being a general rather than a local disease. Tenneson J 
says that daily examination of the whole skin in a case of zoster 

* This he explains by the intrinsic movements of the hand being inner- 
vated by the motor part of the first dorsal root with that of the eighth 
cervical. 

\Jour. Cut. Med., vol. li. (1868), p. 241. 

% References to cases may be found in Lancet annotations, September 
24, 1898, p. 822, and October 27, 1900, p. 1223. 
18 



274 DISEASES OF THE SKIN. 

would show these vesicles in nine cases out of ten. My own 
observations, since my attention has been drawn to the point, 
tend in the same direction. 

Children. — The affection is more common in children than in 
adults, and in girls than boys. The pain is never persistent, as 
in the aged, but the inflammation is more frequently intense 
enough to produce suppuration and gangrenous ulceration. In 
a boy of four, observed by J. Deas, the gangrene was so exten- 
sive as to lead to septic absorption and death of the child. The 
region of the fifth nerve is seldom affected, except in the form 
of febrile herpes. 

Etiology. — In my practice three-fourths of the cases were 
under twenty, and two-thirds of these under thirteen years; 
nearly all the rest were over forty. Head's statistics em- 
phasize the same fact — viz., the prevalence in childhood; and 
three-fourths of all these cases were under twenty-five. 

It is rare in infants, but Bohn records two cases, aet. five and 
seven months respectively, and Lomer records one in an infant 
of four days old. There is no limit at the other end as to the 
possibility of its occurrence; but while old age is not a factor 
as regards frequency, it is as regards the severity of the attack. 

Sex appears to have no influence. One hundred and twenty 
males to 105 females, and 104 right-sided to 93 left (Harrison). 
There is a fairly general consensus of opinion that chills are a 
frequent exciting cause, and the possibility of atmospheric in- 
fluences is favored by the frequent occurrence of cases in 
groups. Hence some, like Erb and Landouzy, regard it as an 
acute specific and infectious disease, and hypothetical microbes 
have been invoked to the aid of the hypothesis, which is also 
supported by Kaposi * on the following grounds : that it geri • 
erally occurs in small epidemics, recurring irregularly, but 
especially in spring and autumn; that it is very unusual for a 
person to be affected twice; that the various epidemics exhibit 
various types, some in which all the cases are slight, while jxi 
others they are all severe, to which he might have added the 
definite course of the disease. Kaposi presupposes a toxic in- 
fluence on the nerve centers. Even if this hypothesis be ac- 
cepted for these groups of cases, it leaves many sporadic cases 

* Kaposi, Wiener med. Wochenschrift, Nos. 25 and 26 (1889). Abs, 
Brit. Jour. Derm., vol. ii., January, 1891. 



HERPES ZOSTER. 275 

traceable to definite causes, so that epidemic influence should 
only rank as one of the etiological items. Thus the occurrence 
of zoster in persons taking arsenic, * first pointed out by 
Hutchinson, of which several instances have come under my 
own observation, have been noted sufficiently often to point 
to an etiological relationship, not inexplicable, since arsenic 
acts on the peripheral nerve ends, and peripheral neuritis is 
sometimes one of its toxic symptoms; an exciting cause, such 
as a chill, is perhaps necessary also. Sattler reports a case 
from coal gas, and Leudet from carbonic oxid poisoning, pos- 
sibly due to a toxic neuritis. 

Severe mental emotion f has appeared to be the exciting 
cause in a good many cases. 

It occurs frequently in epidemic cerebro-spinal meningitis 
and also in cerebral meningitis from other causes, and is then 
usually bilateral; but it is said to be more common in non- 
tubercular meningitis. At the same time it is not infrequent in 
tubercular subjects (Leudet, Barie, Leroux, etc.), and in 
ataxics (Charcot, Fournier, Buzzard, etc.). Various mechan- 
ical peripheral nerve irritations are noticed in the next section 
as exciting causes. Probably Touton's case, in which an 
abortive herpes followed the intra-muscular injection of salicy- 
late of mercury, was from that cause, rather than from the 
nature of the drug. Severe mental emotion has appeared to 
be the exciting causes in some instances. 

Herpes has occurred in several instances as the result of 
contusion or other lesions of the terminal nerve filaments, 
such as on the cheek and eyelids following a blow; lumbo- 
abdominal herpes after a strain; of the forehead, eyelids, and 
cheek, in one case, and right upper dorsal and intercosto- 
humeral in another case (Pernet) after tooth extraction. 
Gaucher and Bernard observed three such cases. Bokai re- 
lates several cases in which an apparent zoster communicated 

* Neiisen found that of 777 cases of psoriasis 557 were given arsenic, 
and among them 10 cases of zoster occurred, i e , 1.8 per cent., while 
not one case occurred in the 220 who received no arsenic and were treated 
with large doses of iodid of potassium. It was frequently noted in the 
Manchester outbreak of arsenical poisoning from beer contamination in 
1900-1901, and was one of the symptoms which led to the detection of 
arsenic as the cause 

f A. Roche, Lancet, October 13, 1894, p. 857, relates and quotes a case. 



276 DISEASES OF THE SKIN. 

chicken-pox; the suggestion offered is that the apparent herpes 
was really a varicella with a circumscribed zosteriform distri- 
bution, or it might be they were cases of unusually abundant 
aberrant vesicles. 

Pathology. — On the whole, the evidence points to the erup- 
tion of idiopathic zoster being due to a toxic inflammation of 
the posterior root ganglion of the nerve area affected. The 
arguments in favor of its being an acute specific poison have 
already been stated, and Head compares it to acute anterior 
polio-myelitis. It has also been shown that in sporadic cases 
various kinds of nerve poisons may set up a similar inflamma- 
tion, or, at all events, produce the eruption of zoster. 

But while the condition most frequent is a descending inter- 
stitial neuritis of the posterior root ganglion, zoster is produced 
by any irritative lesion or condition, in any part of the tract 
from the cord to the periphery of the nerve supplying the 
affected skin. The proofs of this are contained in the following: 

That zoster is a neurosis was inferred by Raver, but was first 
anatomically proved by Baerensprung,* who showed that there 
was an interstitial neuritis of the posterior ganglion, and of the 
trunk of the nerve issuing from it to supply the region of the 
skin, where the eruption was distributed. This observation is 
true for the majority of cases, but not for all, as Baerensprung 
asserted. Weidner f found a lesion of the posterior spinal 
root between the cord and ganglion, they themselves being un- 
affected. Chronic inflammation of the posterior columns of 
the cord has been found associated with zoster, while the pos- 
terior root, the ganglion, and nerve were unaffected. As a 
symptomatic condition it is observed in those diseases espe- 
cially involving the posterior columns, such as tabes and gen- 
eral paralysis of the insane, and in myelitis often at the upper 
level of the anesthesia, or its superjacent hyperesthesia (H. 
Head). Bramwell suggests that bilateral herpes at the-^ame 
level (very rare) is generally due to myelitis. 

Dubler J has demonstrated a peripheral neuritis with absence 
of central disease in a case of zoster, where there were perios- 

* Die Giirtel-Krankheit, Charite-annalen, Bd. ix., Heft 2 and 3 (1861- 
62), Berlin. 

f Berlin klin. Wochenschrift., 1870. 

JVirchow's Archiv., May, 1884, p. 185. Abs. in Brain, 1884, p. 550. 



HERPES ZOSTER. 



277 



teal swellings on the ribs. The neuritis extended into the mus- 
cular twigs, thus accounting for the motor paralysis sometimes 
associated with zoster. 

Curschmann * and Eisenlohr found multiple neuromata in 
the domain of the affected nerves, with the spinal cord and gan- 
glia intact, as were also the nerve fibers in the neuromata, 
which were due to a perineuritis. Neuromata followed herpes 
in two other of their cases, and in those of others since their 
report. 

In a case of widespread herpes Hans Hebra found at the 
necropsy two foci of disease in the cervical ganglion. 

The lesion is not necessarily inflammatory. Wyss and 
Sattler in cases of H. frontalis f found hemorrhage into the 
Gasserian ganglion; hemorrhage into the cauda equina with 
crural herpes has also been found. Charcot had a case due to 
an embolus in a branch of a sacral artery, which pressed 
upon one of the spinal roots of the cauda equina at the 
foramen. 

Nevertheless, interstitial neuritis is the most common lesion, 
irrespective of the origin or position of the exciting cause; thus 
herpes has followed neuritis of the trunk, produced by gunshot 
or other injuries (Mitchell, Morehouse, Kean, etc.), crncer of 
the spinal column and of the pleura (Charcot and Ollivier). 
Leprous deposit and peripheral irritants, e. g., arsenic to de- 
stroy the nerve of a tooth produced herpes of chin, cheek, and 
ear of the same side (Lesser). The application of the galvanic 
current has twice produced it — once where the poles were ap- 
plied (Liveing), and once away from them (Kobner).J Similar 
cases are those after extraction of a tooth, tapping hydatids, a 
hydrocele and psoas abscess, and after re-vaccination (C. 
Thompson). It has also been ascribed to reflex irritation 
(Jewel). Zoster has also been recorded in connection with 
cerebral lesions, but not any special ones except those of gen- 
eral paralysis, in which the posterior columns of the cord are 
often affected also, while in zoster, with other cerebral lesions 

* Quoted in Viertelj.fiir Derm, und Sypk., vol. xvi. (1884), p. 157. 

f The references to the following facts are given in a paper by myself 
on the lesions of the nervous system related to cutaneous disease, in 
October number of Brain, 1884, p. 363. 

% Neurol. Ce?itralbl., May 1, 1890. 



278 DISEASES OF THE SKIN. 

the other parts of the nervous system have not been shown to 
be free from secondary or other changes. 

The most recent and comprehensive examinations of the 
nerve changes are by Head and Campbell,* who examined 
twenty-one cases from a few days to a year and a half after the 
eruption. In the most acute cases they found hemorrhages 
with inflammatory exudation into the root ganglion, destroying 
the ganglion cells more or less completely, and leading ulti- 
mately to proportionate sclerosis of the ganglion. There were 
secondary degenerative changes upwards in its posterior root 
and in the posterior columns of the cord, and downwards of the 
peripheral sensory nerves. 

By mapping out the area of skin affected during life and de- 
termining post-mortem which posterior root ganglion was 
affected, they were able to trace on the neck and trunk the skin 
areas supplied by the various ganglia in many cases, and to 
infer the rest from the skin lesions of other cases. These areas 
do not always correspond with the sensory branches of any 
one nerve, but with several branches of nerves, linked by some 
of their fibers passing through the same ganglion. This dis- 
tribution Brissaud explains by his metameric theory of the 
spinal cord being composed of a series of segments superim- 
posed and relatively independent, and that zona occupies the 
domain of one of these segments. Pfeiffer tried to prove that 
it followed the distribution of the cutaneous arteries, and 
Abadie f contends that it is not the sensory nerves, but the 
vaso-dilator fibers of the sympathetic which are involved. 
Head and Campbell's explanation, as supported by their 
anatomical researches, is probably the correct one as far as 
idiopathic herpes is concerned, but the irritation may ^lso be 
central, as in tumors of the spinal cord, in tabes, and 'general 
paralysis, or peripheral, as in arsenical poisoning, caries of 
rib, etc. 

* " The Pathology of Herpes Zoster and its Bearing on Sensory Locali- 
zation." Reprinted from Br am, autumn part, 1900. John Bale, Sons & 
Danielsson, London, 1900. An important and highly illustrated 
monograph. 

Head's article on " Herpes Zoster," in vol. viii. of Allbutt's " System of 
Medicine," gives a good resume to date, 1899. 

f Barbieri has shown that the posterior ganglia are connected with 
large numbers of sympathetic fibers. 



HERPES ZOSTER. 279 

The anatomy of the eruption itself has been investigated by Biesia- 
decki,* Auspitz, Basch, Ebstein, Haight of New York, Unna, f Hartzell,:}: 
Campbell and Head, § Kopytowski, || etc. They concur in the following: 
that the vesicles are formed, in the upper part of the rete in the same way 
as in eczema, the process proceeding from the papillary layer in which 
the vessels are dilated. The vesicles are unilocular, but subdivided 
imperfectly by the effused fluid forcing its way between the rete cells, 
elongating and compressing them, together with the cells of the sweat 
ducts and hair follicles, into a network, the meshes of which contain 
altered epithelial ceils (protozoa of Pfeiffer) and leukocytes which have 
worked their way thither through the rete. The papillae are enlarged, 
and, together with the corium, infiltrated with leukocytes, which may 
extend into the subcutaneous layer. Inflammatory changes are also to 
be found in the nerve twigs of the corium, which Campbell and Head 
have shown to persist as degenerative changes in the larger branches 
from ten days after the onset of the eruption. Both Bewley and Pfeiffer 
describe cells they consider to be giant cells in the rete, but this inter- 
pretation is not accepted. Kopytowski examined vesicles from sixteen 
cases at various stages. He found the vesicles intercellular in origin, and 
that some of them were multilocular. He found on the whole the same 
changes in the cells as observed by Unna, but does not admit his explana- 
tion of ballooning epithelial degeneration, and considers that the 
pathological process is the same in zoster as that of ordinary inflam- 
mations, and that it is of toxic origin. 

Diagnosis. — The diagnosis of zoster is generally easy enough; 
a unilateral eruption in groups of large vesicles on an erythe- 
matous base, arranged along the course of one or more cuta- 
neous nerves, is sufficient to establish it. The large size of 
the vesicles of herpes, which dry up instead of rupturing and 
emitting a continuous discharge, and the nerve distribution, 
are distinguishing features from eczema. It is sometimes diffi- 
cult to decide between zoster and H. facialis or genitalis, but 
this is not of much practical importance. The presence of pain 
before the eruption, and the existence of several groups uni- 
laterally distributed, or unusual severity in the character of the 
eruption, would be in favor of zoster, while previous attacks 
and a single group, or being on both sides, would indicate the 

* " Beitrage zur Phys. und path. Anat. der Haut," p. 245. (Wien, 1867.) 

fUnna, " Histopathology." 

% Hartzell, Jour. Cut. and Gen.-Urin. Dis., September, 1894. The 
protozoa-like bodies of herpes zoster. 

§ Campbell and Head. loc. tit. 

|| Kopytowski, Archiv. f. Derm. u. Syfih., vol. liv., 1900, p. 17. 
Illustrated. 



2 8o DISEASES OF THE SKIN. 

trivial forms. Many of the reported double zoster cases are 
really H. febrilis, and on the face it may be especially difficult 
to decide, but the more abundant the eruption on both sides of 
the face the less likely it is to be true zoster. According to 
Thibierge, ophthalmic zoster always scars — I should have said 
nearly always. The other herpetiform eruptions are always 
bilateral. 

Prognosis. — Unless the lesions are more severe than usual, 
two or three weeks are nearly always sufficient to bring zoster 
to a favorable termination; but continuous irritation of the 
nerve or its branches may lead to prolongation by the forma- 
tion of fresh groups, and of course when there is ulceration or 
gangrene longer time is required for repair. 

Treatment. — Since the tendency is to run such a short, favor- 
able course, treatment is fortunately scarcely required. It is 
very doubtful whether we can shorten its duration, and very 
difficult to decide whether a rather shorter course than usual is 
spontaneous or due to the drug employed. Ashburton Thomp- 
son and Bulkley, however, state that one-third of a grain each 
of phosphid of zinc and nux vomica extract at the commence- 
ment, and every three hours afterwards, control the pain and 
abort the eruption. Where the neuralgia persists, antipyrin or 
phenacetin in ten-grain doses, quinine in full doses, iron, 
strychnia, arsenic, salicylate of soda, and cod-liver oil and a 
highly nutritious diet, generally offer the best chance of com- 
bating the neuritis; blistering over the nerve root and hypo- 
dermic injections of morphia are sometimes required. Ex- 
ternal treatment is useful to protect from irritation and to allay 
the pain or discomfort. Dusting powders of starch or zinc, 
with morphia and camphor added where there is much smart- 
ing, put thickly on cotton wool and bandaged on, give great re- 
lief. Calamin lotion painted on frequently and allowed to dry 
will sometimes diminish the severity of the lesions, if com- 
menced sufficiently early. 

Collodion painted on has appeared to me to hasten the ab- 
sorption of the fluid and drying up of the vesicles; the addition 
of morphia is often desirable here also. The local treatment 
for persistent after-pain is hypodermic injections of morphia, 
and repeated blistering over the root of the nerve, which in 
some cases has answered admirably in my hands. Counter- 



HERPES FACIALIS. 281 

irritation is also recommended at an early stage at the tender 
spot, where the cutaneous trunks pierce the fascia, and is said 
to relieve both the pain and the eruption. Rubbing the part 
with menthol or chloroform epithems gives temporary relief, 
but better than all, in some cases, is the continuous current ap- 
plied in the course of the nerve; from ten to twenty cells of a 
Leclanche battery should be applied for about ten minutes 
daily. Duhring says that the continuous current applied be- 
fore the appearance of the eruption will sometimes render the 
impending attack abortive, but this I have not tried; he also 
recommends oss to oj of the fluid extract of grindelia in gj of 
water as a lotion. Leloir and his pupil Dupas strongly ad- 
vocate the use of alcohol with two or more per cent, of 
resorcin, thymol, menthol, or other antiseptic, applied con- 
stantly on pads either to abort or shorten the course of the 
disease. 

HERPES FACIALIS.* 

Synonyms. — Herpes labialis; Herpes febrilis; Hydroa febrilis. 

Definition. — A herpetic eruption, occurring chiefly on the 
lower part of the face. 

This eruption is very common, and occurs most frequently 
round the mouth, especially on the lower lip, but it may appear 
on any part of the face below the forehead, on the auricle, on 
the mucosa of the conjunctiva or of the mouth, such as that of 
the cheeks, palate, uvula, pharynx, tonsils, and larynx; and 
Barthelemy mentions a case, in an old woman dying of pneu- 
monia, in whom some patches on the chest, with very large 
vesicles, were referable to herpes febrilis rather than to zoster. 
It comes out suddenly, with heat and tension of the part, fol- 
lowed in a few hours by a slightly papular eruption, which soon 
becomes vesicular on a reddened base. The vesicles enlarge to 
the size of a hemp seed or a small pea, are arranged irregularly 
in one or more groups of six to twelve each, and in a few days 
dry up and form small scabs, which drop off a few days later, 

♦Author's Atlas, Plate XVI., Figs. 2 and 3, one showing bilateral dis- 
tribution. Kaposi's Hand Atlas, Plate 105, is also symmetrically bilateral, 
the lower part of the face being free. There is no history, but it was 
more probably H. febrilis than zoster. 



282 DISEASES OF THE SKIN. 

leaving only transitory reddened marks, the whole process 
occupying eight to ten days. I have once seen a gangrenous 
spot a quarter of an inch in diameter in an H. labialis. 

In the vast majority of cases, as Hutchinson first pointed out, 
shivering, or at least a sense of chilliness, precedes the erup- 
tion, and there is often a considerable rise of temperature, due, 
however, to the disease in which the eruption is an incident. It 
is therefore chiefly met with in those diseases in which shivering 
is a prominent symptom, such as febrile colds, pneumonia, 
ague, tonsillitis, etc., but only occurring once in each attack. 
Vogel says that in predisposed persons local irritation, such as 
contact of the lips with pepper and salt or other spices, and 
even healthy saliva, will produce an attack. 

It is a prominent feature in cases of so-called " herpetic 
fever," which are reported from time to time, often occurring 
endemically, and the eruption may be extensive. In all these 
cases " shivering " is a prominent symptom, and in no other 
way is the herpes related to the symptoms or cause of the en- 
demic, which has in some cases been traced to defective 
hygiene, especially sewer-gas poisoning. The herpetic out- 
break is in some cases associated with defervescence. Epi- 
demics of this kind have been reported by Savage,* Seaton,f 
Lake of Teignmouth, etc. 

Pathology. — Its connection with shivering suggests a neurotic 
origin, possibly a reflex irritation of the sympathetic ganglia of 
the affected region through the fifth nerve. The following case 
of Sulzer of Paris is susceptible of such an explanation, al- 
though the possibility of a septic origin cannot be excluded. 

In 1891 forced dilatation of the urethra was followed by an 
herpetic eruption of the right cornea, a similar operation in 
1896 was followed some hours afterwards by violent chills and a 
temperature of 105. 3 F., delirium, and three days' uncon- 
sciousness. The whole face was covered with an herpetic erup- 
tion, which also involved the buccal, pharyngeal, and nasal 
cavities, the eyelids, conjunctivae, and corneas. The patient was 
in bed for six weeks, and the left eye got well, but an herpetic 
eruption of the right cornea recurred every three weeks; as 

* Lancet, January 20, 1S83, and January 28, 1899, P- 2 5 2 » a sporadic 
case. 

\Clin. Soc. Trans., vol. xix. (1886), p. 26. 



HERPES FACIALIS. 283 

soon as one crop got well another appeared, and the left eye 
was again attacked. These attacks lasted three months. Tem- 
porary increase of previous astigmatism occurred, but he 
eventually got well. 

St. Clair Symmers * has isolated a microbe from the vesicles 
of a pneumonic herpes labialis. It was of either rod or thread 
form, and in the presence of oxygen when cultivated on gelatin, 
but not on potato, developed a pea-green pigment, resembling 
that of Frick's bacillus virescens, and different from pyocyanin. 

Prognostic Significance. — Its frequent occurrence in sthenic 
pneumonia, which begins with a rigor and runs a pretty definite 
course, whilst it is less likely to occur in asthenic pneumonia, is 
perhaps the foundation for the notion that herpes is of good 
prognostic significance in pneumonia, a view advocated by 
Germain See; but as a rule it is rather only an evidence of 
febrile disturbance, past or present, with shivering. Ornstein's 
statement that in ague whitish-yellow crusts point to a slight 
fever, brown ones to a more severe, and painful crusts to per- 
nicious attacks, requires confirmation. Unless irritated it in- 
variably takes a favorable course, but in a few instances tends 
to recur for years, often without apparent cause. Thus one of 
my patients, a lady aet. seventeen, had one or two attacks a year 
from her earliest childhood, and she could not connect it with 
any definite cause. Another case, a gentleman set. fifty-nine, 
doubtfully gouty, had had it five successive years, " excited by 
the summer sun and the sea air," rarely under other circum- 
stances. In both these cases the eruption was on the lower 
lip, but not always on the same place, but it may recur in other 
parts of the face. Like its congener, herpes progenitalis, 
gouty conditions predispose to attacks. Dubreuilh has written 
a paper on " Recurrent Herpes " (not zoster), in which he re- 
lates several similar cases. 

Treatment. — The only treatment required is protection from 
irritation, which may be afforded by calamin lotion, which also 
allays itching, and if commenced early may diminish the 
severity of the attack. Starch and zinc dusting powders or 
weak boric acid ointment are also good applications. Hutch- 
inson believes that the recurrent form is definitely controlled by 
the use of arsenic. 

* Brit. Med. Jour., December 12, 1891, p. 1252. 



284 DISEASES OF THE SKIN. 

HERPES PROGENITALIS. 

Synonym. — Herpes preputialis. 

Definition. — An eruption, consisting of vesicles in a group, on 
an inflamed base, occurring on the genital organs of both sexes. 

This eruption is not uncommon, and would be of small im- 
portance were it not that its frequent recurrences give great 
annoyance to the patient and excite apprehensions of syphilis. 
In men it occurs most frequently on the inner surface of the 
prepuce, less often on the outer surface, in the sulcus, glans, 
meatus, the sheath of the penis, or even in the urethra (Diday). 
In women its most common position is on the inner or outer 
surface of the labia majora, on the mons veneris, and occa- 
sionally on the nymphse, or prepuce of the clitoris, and on the 
cervix uteri near the os externum. Obviously, therefore, the 
name most frequently used, H. preputialis, is inappropriate. 

The eruption is preceded by itching and burning of the part, 
followed in a few hours by the development of a vesicle or a 
group of vesicles, seldom more than one group, on an erythe- 
matous base; there may be swelling and edema of the prepuce. 
The vesicles are the size of a pin's head, contain a clear fluid, 
and when on a moist surface look like opaque white specks; 
they rupture in a few hours, leaving tiny excoriations, which 
heal in two or three days. When on an external part they dry 
up, leaving a little scab, which soon falls off. The whole 
process is a matter of a week or less. 

Variations. — When irritated, c. g., by repeated sexual inter- 
course, mistaken zeal in the use of caustics, etc., the disease 
may be kept up for weeks from ulceration, which may spread 
and suppurate freely, with tenderness and enlargement, and 
even suppuration of the inguinal glands * (Berkeley Hill). Se- 
vere neuralgia of the branches of the sacral, pelvic, or sciatic 
nerves, or gangrene of the site of the eruption, as Mauriac f 

* Taylor and Bumstead, in their work on syphilis, relate a case where a 
man had sciatica four times a year for ten years, and seven times out of 
ten with herpes of the penis. 

f Mauriac relates somewhat similar cases of neuralgia in " Herpes 
nevralgiques des organes genitaux"; and in his "Ulcerations non 
virulentes des organes genitaux," 1878, p. 49, gives a case of gangrene 
with H. progenitalis. 



HERPES PROGENITALIS. 285 

describes, is to be explained by such cases being examples of 
H. zoster, rather than H. progenitalis. On the other hand, in 
Lausseday's * case herpes recurred in a patch on the sacro- 
lumbar region at every catamenial period for five years, except 
during three months, when she had influenza and bronchitis, 
and this evidently belongs to the present affection and not to 
zoster. A similar case has come under my own observation, 
but with fewer recurrences and not connected with the cata- 
menia. Dubreuilh cites similar cases. 

Etiology. — It is much more common in men than women, and 
is usually, but not always, as Doyon asserts, preceded by 
venereal disease, such as gonorrhea, or a soft chancre. It 
comes out most frequently two or three weeks after the sore is 
healed, or the gonorrhea cured. It recurs every two or three 
months, or, in some cases, at regular intervals of three weeks 
or a month, the recurrences being generally determined by 
local irritation, especially coitus, passing a catheter, etc. For 
my own part, I am more inclined to ascribe it to such local 
causes than to internal disturbances, though it may arise from 
the gouty diathesis, excesses in eating or drinking, dyspepsia, 
or exhaustion from any cause, provided that the last attack is 
not very recent. These recurrences may last for years, and 
then cease, unless the tendency is reawakened by fresh local 
venereal troubles. On the other hand, the relapses are some- 
times permanently interrupted by a severe general illness, such 
as smallpox, syphilis, etc. (Berkeley Hill). 

Pathology. — The presumption is in favor of the disease being 
due to a reflex excitation of the neighboring sympathetic 
ganglia, through irritation of the sensory nerves of the 
part. 

Diagnosis. — No difficulty can arise in a simple case. The 
group of small vesicles on a red base is quite characteristic; 
but when not seen until suppuration has occurred it may easily 
be mistaken for a soft sore. When a group has coalesced the 
resulting excoriation can be seen with a lens to have a gyrate 
outline — occasionally there is only a single vesicle, when the 
possibility of its being herpes will probably be overlooked. 
The chancre is flattened at its base and secretes scarcely any 
liquid, whilst, according to Leloir, the herpes discharges a large 
* Ann. de Derm, et de Syftk., vol. ii. (1891), p. 408. 



286 DISEASES OF THE SKIN. 

quantity of serous fluid when pressed, and is reduced in size; 
but in some cases nothing but time or auto-inoculation can de- 
cide positively. In a few days, if the parts be kept separated 
and iodoform applied, the ulcer will clean and begin to heal, 
while a soft chancre will take longer before improvement 
sets in. 

Treatment. — Wash the parts two or three times a day, and 
keep the surfaces apart with a piece of lint soaked in weak lead 
lotion, or with wetted boracic lint, which I have found answer 
admirably; or dry carefully and apply starch and zinc powder, 
and put a strip of lint or linen over it. Where suppuration has 
occurred, iodoform, followed by lotio nigra, would be appro- 
priate, with rest, if the glands are enlarged. To prevent recur- 
rences the patient should be enjoined to wash carefully imme- 
diately after coitus, and also daily. Circumcision has been 
recommended where the prepuce is long, but often fails, the 
eruption coming elsewhere. The gouty diathesis should be 
combated by appropriate measures, such as giving alkalies, 
regulating the diet, avoiding fermentable liquids, such as beer, 
champagne, etc. Doyon * says, in an interesting and ex- 
haustive essay on the subject, that the waters of Uriage, of 
which he is the inspector, are the best means of cure for such 
cases. 

Persistent Balanitis. A constantly recurring surface inflam- 
mation and excoriation of the glans penis and prepuce is some- 
times seen in elderly men from sixty to seventy. One of my 
cases began as a recurrent herpes, but no cause is ascertainable 
in most instances. The surface for a variable extent remains 
superficially excoriated with a sharply defined border. Even 
if it heals for a time, it is almost sure to break down again, 
either in the same or another place. Such cases are apt to 
degenerate into epithelioma. 

Hutchinson, who has written on the subject, says it is in- 
curable, but much may be done for it by persistently using 
microbicides. 

A i in 8000 to 1 in 6000 perchlorid of mercury solution on 
lint may be applied, and if, after a day or two, it is beginning to 
irritate, wet boric lint may be substituted, returning to the 

*Doyon, " Del'Herpes recidivant des parties genitales." (Paris, 1868.) 



POMPHOLYX. 287 

perchlorid when the irritation has subsided. In one case 
touching some of the obstinate spots with pure formalin at the 
end of a match was effectual in healing them. 

Zoster Atypicus Gangrasnosus et Hystericus (Kaposi). Vide 
Hysterical Gangrene. 



BULLOUS ERUPTIONS. 

Bullae may occur as an occasional or constant feature in a 
large number of acute inflammations of the skin, in some toxic 
general diseases, and in some neuroses. 

Thus there are bullous forms of urticaria, erythema ab igne, 
and erythema multiforme, but these are exceptional, while 
herpes iris is frequently bullous, and in impetigo contagiosa it 
is fairly common. 

In vesicular eruptions, like eczema and herpes, bullae may 
be formed by coalescence. Some drug eruptions, of which 
quinine may be especially mentioned, take a bullous form, and 
external irritants often excite bullae or blisters, chiefly depend- 
ing on the severity of the irritant. Rhus toxicodendron and 
primula obconica may be instanced among vegetable, can- 
tharides among animal, and arsenic among mineral irritants. 

Bullae are an occasional feature in some of the exanthemata, 
such as scarlatina and varicella, and are quite common in 
erysipelas. 

Bullae also occur in the symptomatology of syphilis, both 
congenital and acquired, in the early and late stage of leprosy, 
and in various lesions of the nervous system, both central and 
peripheral. 

The essentially bullous eruptions now to be considered are 
pompholyx, epidermolysis bullosa, pemphigus, dermatitis her- 
petiformis, and some other forms of hydroa, while there are a 
good many cases of anomalous bullous eruption which are not 
classifiable with our present knowledge. 



288 DISEASES OF THE SKIN. 

POMPHOLYX.* 

Deriv. — 7to^.cp6\v^ y a bubble. 

Synonyms. — Cheiro-pompholyx (Hutchinson) ; Dysidrosis f 
(Tilbury Fox). 

Definition. — A vesicular and bullous eruption limited to the 
hands and feet. 

This disease was described originally by Tilbury Fox in 1875, 
and, independently, by Hutchinson, from the same case. I 
have adopted the American name, as it does not assume any 
pathological theory. 

The disease is not a common one, and the more severe forms 
are rare, but I have seen a good many cases since Tilbury Fox 
first pointed out its characters to me. 

It is a disease that is seen chiefly in the summer, and is limited 
almost exclusively to the hands and feet, and while symmetrical 
in the main, one side is often worse than the other. The 
hands are always affected, while the feet often escape, and are 
seldom so bad as the hands. The eruption commences with 
burning and tingling, and development of deeply imbedded 
vesicles, singly or in groups, along the sides of the fingers and 
on the palms, but no part is exempt; in bad cases the whole 
surface of the hands is affected. In the earliest stage I have 
repeatedly verified Fox's observation, that small transparent 
rings of fluid are visible round the sweat orifices; but this can- 
not be demonstrated, as they become larger, when they have 
been aptly compared to boiled sago grains imbedded in the 
skin; at the same time too much stress has been laid on this 
appearance, as it is due more to the anatomical constitution of 
this part of the skin than to any peculiarity in the process. 
When the vesicles are grouped they frequently coalesce into 
larger bullae with irregular outlines, which project considerably 

* Literature. — "On Dysidrosis," Tilbury Fox, Amer. Jour, of Derm., 
1875, p. 1. 

"Cheiro-pompholyx," Hutchinson. "Illustrations Clinical Surgery," 
London, 1878. Vol. i., Plate X., colored. 

f G. T. Jackson's dysidrosis is a different affection, described under 
Hidrocystoma. 



POMPHOLYX. 289 

above the level of the skin. The contents both of vesicles and 
bullae are neutral, or alkaline, perfectly clear at first, though 
the older ones are turbid. When fully developed the hands 
are covered with vesicles and bullae from one-sixteenth to one 
inch or more in diameter, with swelling and tension, but with 
little or no redness of the skin; in ten days or a fortnight the 
contents are absorbed, for the vesicles never rupture spontane- 
ously, and the detached epidermis is exfoliated, or can be cut 
off, exposing the red delicate new skin, which never discharges 
like an eczema; this soon hardens, and the disease is well, but 
is very likely to recur in the following year, or later. During 
and before the eruption the hands are often in a condition of 
hyperidrosis, and it is most frequent in damp-handed persons, 
who are nearly always out of health at the time of attack. 

The following case is a fairly typical example, and illustrates 
most of its features: 

George T., aet. thirty-six, carpenter, came to the hospital on 
January 23, 1883. He first suffered from the eruption six 
years previously; since then he has had one or two attacks a 
year, all but the present one having been in the summer; it is 
especially likely to come on when he is out of health and living 
badly. The feet are sometimes affected, but never severely. In 
this attack both hands were involved, but the right was much the 
worse. There were large bullae and vesicles on the palmar 
surface of the hands and fingers, and there were vesicles along 
the sides of the fingers, but the backs of the hands were free; 
the vesicles and bullae were from one-eighth to one inch in 
diameter, the smaller ones rounded, the larger irregular from 
coalescence. No connection with the sweat ducts could be 
traced, but none of the vesicles were in the earliest stage. His 
general health was now good. He was ordered perchlorid of 
iron internally and oleate of zinc ointment, and in a week was 
sufficiently well not to attend a third time. 

Variations. — Many authors include in this category the very 
slight cases, which are not uncommon, where there are simply 
a few " sago grain " vesicles along the sides of the fingers, com- 
ing on in hot weather in moist-handed persons, with or without 
slight derangements of health, and itching rather severely, dry- 
ing and disappearing in a few days. I consider it a separate 
affection. 



290 



DISEASES OF THE SKIN. 



In a few cases an eruption, generally of an eczematous aspect, 
appears on the arms or elsewhere, and occasionally the disease, 
instead of getting well quickly, lasts several weeks. 

Etiology. — It occurs in both sexes, but is much more common 
in women. Hutchinson says he has never seen it below 
puberty or in old persons. The youngest I have any record of 
was a girl of twelve (Waren Tay had a case aged nine), the 
oldest a woman of fifty-four. It is most common in young 
women of nervous temperament, is especially liable to occur 
when they are broken down in health from worry or excite- 
ment, or other cause of nervous depression. The above state- 
ments apply to the severe typical cases. The cases of a few 
vesicles along the sides of the fingers in hyperidrotic persons 
only require hot weather for their reproduction. 

Pathology. — There has been much dispute about the pathol- 
ogy, chiefly as to whether it is a disease of the sweat glands, 
Fox affirming, Hutchinson, Breda, and Unna denying this. 
For my own part, on clinical as well as anatomical grounds, I 
think the disease is intimately connected with the sweat appa- 
ratus, but I should rather connect it with hyperidrosis than 
dysidrosis. Primarily, however, I think the disease is of neu- 
rotic origin, probably a vaso-motor neurosis leading to inflam- 
mation in and about the sweat apparatus, but not limited to 
those structures. 

Anatomy. — This has been investigated by Fox * and myself conjointly, 
by Robinson f of New York, by myself since independently, and by W. 
Williams, % Breda, G. and F. E. Hoggan, § etc. There is such a discrep- 
ancy between the observations that it is a question whether the same 
affection has always been under examination. Robinson, Williams, and 
Breda all affirm that the disease has nothing to do with the sweat appa- 
ratus. Breda saw a sweat duct traverse a vesicle without having any 
communication with it. How this could be, as the sweat ducts in the 
rete have no walls, is not evident. Williams also in serial sections found 
no connection with the sweat duct. Judging from his description, he 
was examining the mild cases on the sides of the fingers already 
described as probably a separate affection, and Breda probably did the 
same, as the typical form is too rare to get many cases in a short time. 
Unna has found a special bacillus, and claims the disease as a local 

* Pathological Transactions, vol. xxix. (1878), p. 264. 

\ Archives of Dermatology, vol. iii., No. 4 (1877), p. 289. 

\ Brit. Jour. Derm., October, i8gi. 

§ Hoggan, Monatsh.f. Derm. (1893), pp. no and 148. 



POMPHOLYX. 291 

infection, but no one accepts this view besides himself. The Hoggans 
and myself, while finding the sweat ducts frequently in connection with 
the vesicles, admit that they are not always so in all the vesicles, which 
may be either superpapillary or interpapillary. 

Fox and I, in the first examination of the disease in an early stage, 
showed that many of the earliest vesicles, which are always formed in 
the rete, somewhat more in the upper part, were directly in the line, and 
interrupted the course, of the sweat duct, and in some of the coils there 
were signs of inflammation. Robinson, on the other hand, found the 
vesicles nearer the top of the rete and over the papillae, and he could find 
no connection with the sweat ducts and glands. Having obtained some 
skin from another patient I found the following conditions, which I give 
in greater detail as they have not been published elsewhere. 

The vesicles were always formed in the rete, generally in the upper 
part close to the horny layer, but sometimes in the middle, and occasion- 
ally quite low down. They could be shown to be distinctly in the line of 
the sweat duct sometimes, and a sweat duct could be distinctly seen leav- 
ing the vesicle, and it was, therefore, distinctly in the interpapillary part. 
In other parts, although there was no sweat duct in the section, the 
vesicle could be shown to be in the interpapillary process. On the other 
hand, and that, too, sometimes in the same section, some vesicles were 
evidently over the papillae, and occasionally a sweat duct could be traced 
between the vesicles. On the whole, there were probably more vesicles 
over papillae than between them. Slight proliferation of the sweat-duct 
cells could be seen in the upper part, and even sometimes in the lower, 
but in no case could I satisfy myself that the sweat coil was inflamed. 

These observations apply to only the smallest vesicles; when compara- 
tively large, they encroach upon and destroy the whole of the rete, but 
seldom raise up the horny layer. The papillae near the vesicles were 
infiltrated with leukocytes, but not densely; leukocytes were also to be 
seen near the upper wall of the vessels of the papillary layer, but not 
near the lower, and there was seldom any sign of inflammation round the 
deep vessels; indeed, the main feature was that the inflammatory process 
was almost confined to the papillary layer, and that it was of very moderate 
intensity. 

Diagnosis. — The most characteristic features are its limita- 
tion to the hands and feet, the tendency of the vesicles not to 
rupture, but to dry up, the spontaneous recovery, and the 
tendency to recur repeatedly, especially in the summer time. 
In these particulars it differs from vesicular eczema palmarum, 
which it otherwise closely resembles, for here when vesicles 
form they rupture spontaneously, and expose a weeping sur- 
face instead of a dry one as in pompholyx. The position and 
formation of the bullae by the coalescence of the vesicles are 
enough to distinguish it from pemphigus. 



292 



DISEASES OF THE SKIN. 



Prognosis. — This is good for each attack, which will probably 
be well in a fortnight, but it. is almost sure to recur at some 
time or other. 

Treatment. — Internally, iron and strychnine, or quinine and 
iron, are generally required. Arsenic is strongly recom- 



-a 




Fig. 18. — Pompholyx. X 150. 

b, Vesicle formed in the interpapillary portion of the rete directly in the 

course of the sweat channel a and c. 



mended by Robinson, but all my cases have got well quickly 
enough without it. 

Since the patients are almost always depressed, and other- 
wise out of health, efforts to improve their surroundings ought 
to be made, the mind diverted, and change of air and scene 
should play an important part in the treatment, but it must be 
confessed that the patients, most frequently of the poor class, 
manage to dispense with these luxuries and get well in a short 
time. 



EPIDERMOLYSIS BULLOSA HEREDITARIA. 



293 



Locally, one of the oleates is most suitable. Oleate of zinc 
or lead ointment should be spread thickly on strips of linen 
and closely applied, doing up each finger separately; this gives 
great relief to the tingling and tension, and the inflammation 
soon subsides, and healing follows. 

For the slight cases at the sides of the fingers painting with 
calamin lotion two or three times a day is sufficient for the at- 
tack, and in a few troublesome cases argent, nitrat. gr. v. and 
sp. seth. nitrosi gj painted on once a day; but as it discolors the 
skin it should be reserved for obstinate cases. Arsenic inter- 
nally, when there is frequent recurrence, is sometimes success- 
ful in stopping it, and perhaps this is the class of case in which 
Robinson used it. 



EPIDERMOLYSIS BULLOSA HEREDITARIA, OR 
CONGENITAL TRAUMATIC PEMPHIGUS.* 

Tilbury Fox described two cases in 1879, but Goldscheider's 
case in 1882 was more clearly differentiated. The children are 
born with a liability to the formation of bullae after the smallest 
physical provocation. The excessive vulnerability shows itself 
in the first month of life, and is said to improve at from forty 
to fifty and cease in old age, but Augagneur's case had it still 
at sixty-four, and Hallopeau's at fifty-five. It is strongly 
hereditary, often through several generations (five in Bonai- 
uto's case); it shows also a family prevalence, and is rather 
more frequent in males than females. The slightest injury, 
blows, pressure, friction, or scratching, is followed by the for- 
mation of a bulla, sometimes preceded by intense itching and 
redness. The bullae are often hemorrhagic and of large size, 
two inches across or more, and their shape may be irregular 
from the nature of the injury instead of round or oval. Al- 

*I. Wallace Beatty, Brit. Jour. Derm., vol. ix. (1897), P- 30 1 , gives an 
excellent historical resume to date. 

II. Abs. of Bonaiuto's comprehensive paper, with resume of forty-eight 
cases, in Brit. Jour. Derm., vol. v. (1894), p. 317; other abs. vol. ix., xi., 
and xii. 

III. Hallopeau, Annates de Derm., vol. ix. (1898), p. 721, with many 
references. He subdivides the cases into a simple, a dystrophic, and an 
attenuated form. 



294 DISEASES OF THE SKIN. 

though the bullae appear to be quite superficial, either from 
repetition in the same place, and possibly sometimes from sec- 
ondary pus infection, they frequently leave atrophic or even 
thickened scars; and milium, as in other forms of pemphigus, 
has been repeatedly observed (Hallopeau, Beatty, Colcott 
Fox, etc.). 

The parts most exposed to injury, the hands, feet, and bony 
prominences (c. g., elbows and knees), are the favorite sites for 
the bullae and their scars; at the same time, bullae come out 
apart from injury, and from no ascertainable cause, even in the 
mouth. The fingers and the nails are very often deformed or 
altogether destroyed, but I have seen them unaffected. 

It was associated with ichythyosis in a case of Startin's and 
in one of my own. Atrophic * changes, even where there have 
been no bullae, such as thinning and lentiginous pigmentation, 
are sometimes seen. In adults, with ordinary pemphigus, in- 
jury will sometimes determine the development of a bulla, and 
in a case under Colcott Fox,f a woman of fifty-one, after hav- 
ing had pemphigus for nine years, she ceased to have acute 
outbreaks, but acquired the same vulnerability as the con- 
genital cases, both in the skin and mucous membranes. 

PatJwlogy. — This is obscure. There is probably an excessive 
irritability of the vaso-motor nerves analogous to that of urti- 
caria factitia. It is uninfluenced by arsenic. Elliot J excised 
a bulla, and showed that there is a raising up of the greater 
part of the rete, but Bonaiuto stated that the bleb occupied the 
horny layer, and did not affect the rete, but the tendency to 
scar shows that this must be exceptional. Bettmann found 
that the whole epidermis was not lifted up. Elliot's further ob- 
servations showed that in apparently normal skin of such pa- 
tients there were degenerative changes in the rete just above 
the basal layer. He considers that it is not a real disease, but 
a cutaneous condition with increased vascular irritability. The 
evidence as to eosinophiles in the bullae is conflicting. 

* Vide Bettmann's cases. Archiv.f. Derm. u. Syph,, vol. lv. (1901), p. 
323. Three red-haired brothers all began at twelve years of age, just 
after revaccination. They all suffered from epistaxis and lentiginous 
pigmentation, with atrophic changes on the backs of the hands. 

\ Brit. Jour. Derm., vol, ix. (1897), p. 341. 

XJour. Cut. and Gen.- Ur. Dis., January, 1895, and A r . Y. Med. Jotir., 
April 21 and 28, 1900. Abs. Brit. Jour. Derm., vol. xii. (1900), p. 256. 



PEMPHIGUS. 295 

Diagnosis. — Hallopeau * describes cases of what he calls 
" congenital bullous dermatitis with epidermic cysts," of which 
also Vidal and Besnier have had examples, and thinks they are 
different from epidermolysis bullosa because of (1) The inflam- 
matory character of the eruption; (2) the predilection for the 
dorsal surface of the articulations; (3) the non-affection of the 
palms and soles; (4) the cutaneous atrophy^ the permanent 
cicatrices, and the loss of the nails; (5) the epidermic cysts; (6) 
the bullae may develop without apparent traumatism; and 
(7) the acute outbreaks following nerve distribution areas. Ex- 
cept the last I have seen all the above distinctions broken 
through in different cases, and do not, therefore, regard Hallo- 
peau's cases as really distinct. 

PEMPHIGUS. 

Deriv. — ne^cpi^, a blister. 

Synonyms. — Pompholyx; Fr., Pemphigus; Ger., Blasenaus- 
schlag; Pemphigus. 

Definition. — An acute or chronic eruption characterized by 
the formation of bullae in successive crops, usually without ante- 
cedent lesions. 

The disease is a rare one, occurring about once in 500 cases 
of skin disease in England and America. Kaposi's statistics of 
over 44,000 cases give 1 in 210; but he includes some bullous 
eruptions not classed under pemphigus by English writers. 
My own statistics, taking pemphigus and dermatitis herpeti- 
formis together, give 4.4 per 1000. 

Before describing what pemphigus is it will clear the ground 
to briefly state what the affections are which either have or had 
the name of pemphigus, but no longer enter into the modern 
conception of the disease. 

In former times, when the objective lesion was the sole 
ground for diagnosis, many symptomatic or other bullous erup- 
tions were classed as pemphigus. Thus P. Leprosus and P. 
Syphiliticus are the bullous eruptions of leprosy and syphilis, 
and are described under their appropriate heads. 

* Hallopeau, Annates de Derm., vol. vii. (1896), April No., and also 
p. 453- 



296 DISEASES OF THE SKIN. 

P. neonatorum is now known to be a pus cocci affection, and 
pemphigus contagiosus and P. contagiosus tropicus are of 
similar if not identical origin. (Vide Pus Cocci Diseases.) 

Congenital pemphigus is described under Epidermolysis 
bullosa. 



P. neuroticus, although not considered a true pemphigus, is 
a convenient term for the various outbreaks of bullae which 
occur in the course of certain diseases after injuries, most of 
which are connected distinctly with irritative or paralytic nerve 
conditions, the irritative being the more important. Although 
many instances of associated cerebral disease with bullous 
eruptions are on record,* I am not aware of any uncomplicated 
with cord disease; e. g., bullous eruptions on the lower extremi- 
ties are frequent in general paralytics, in whom posterior 
sclerosis of the cord is also very common. 

Dejerine records a case in which, twelve days before death, 
pemphigus broke out on the extremities, and post-mortem 
there were diffuse periencephalitis, sclerosis of the lateral 
columns, and degeneration of the peripheral ends of the nerves 
under the bullae. In locomotor ataxy bullous eruptions are not 
infrequent, and in three well-marked cases sclerosis of the 
columns of Goll was the principal change found post-mortem, 
where during life there had been extensive bullous eruptions. 
Bullous eruptions are fairly common with chronic myelitis and 
acute spinal meningitis. Balmer f gives three instances in 
which pemphigus occurred in progressive muscular atrophy, 
but there is no proof that the lesion in the cord was limited to 
the anterior cornua. Mitchell gives several instances of bul- 
lous eruptions following nerve injuries, those setting up neuritis 
being chiefly to blame ; where the nerve is completely paralyzed 
bullae occasionally form after exposure to heat or cold, or the 
like, and the early and late bullous eruptions of leprosy afford 
examples of disease of the nerve, producing similar effects. 

* Leloir, loc. cit. Two recorded by Schwimmer, in his " Die neuropathi- 
schen Dermatonosen," cases 13 and 14, p. 148 et seq.; case 12 is also 
interesting; one by Meyer of Strasburg, in Virchow's Archiv., November 
5, 1883; full abstract in Brain, January, 1885. 

f Balmer, Archiv. fiir Heilkitnde, 1875, p. 317. 



PEMPHIGUS. 297 

Dejerine, Quinquaud, Leloir, Jarisch, and Mott * found de- 
generation of the peripheral nerve ends in five cases of pem- 
phigus, but in all there were central changes as well. Again, 
Mott and Wright f found lesions in the small cutaneous 
branches of the anterior crural nerve, and in its spinal ganglia 
in a case of general paralysis with a gangrenous bullous erup- 
tion. Still the evidence goes to show that bullous eruptions 
may occur in connection with, and probably indirectly due to, 
lesions of the nervous system situated anywhere from the 
center to the periphery of the sensory tract, though similar 
lesions are much more frequently found with no bullae; and 
that irritative lesions have much more effect than paralytic 
ons in their production, an external excitant being necessary 
in paralytic lesions, in which also the bullae are solitary or few 
in number. \ 

P. hystericus is a variety of P. neuroticus in which nerve 
lesions are usually not demonstrable. It is a rare bullous 
tropho-neurosis in which the distinction from a true pemphigus 
is not always easy to make, except from the kind of patient in 
whom it is met with. 

From time to time these cases are reported in women, mostly 
young, and pronounced hysterics, and as a rule the outbreaks 
follow or alternate with other recognizably hysterical phe- 
nomena; but in some cases these latter may be wanting in rela- 
tion to the bullae, although the neurotic temperament of the 
patient is evident enough. In a patient of Du Mesnil de 
Rochemont, § who had annual attacks from the age of seven, 
when aet. twenty-nine simple verbal suggestion would bring out 
typical bullae in another, and the hysteria went on to mania and 
dementia. Other vaso-motor disturbances are often present, 
such as tachycardia and redness and burning of the skin before 
the bullae appear. 

*In a case of Sangster's read before Med. Chir. Soc., Brit. Med. Jour., 
June 16, 1888. 

f Archives of Neurology, vol. i. (1899), an d Brit. Jour. Derm., vol. xii. 
(1900), p. 29. 

%Archiv. f. Derm. u. Syph., vol. xxx. (1895), p. 103. Good abs. in 
Annates, vol. vi. (1895), p. 842. 

§ Archiv. f. Derm. u. Syph., vol. xxx. (1895), p. 163. Good abs., in 
Annates, vol. vi. (1895), p. 842. 



298 DISEASES OF THE SKIN. 

In Boradet's case, a pronounced hysteric of seventeen, suc- 
cessive bullous outbreaks appeared for months on the hands, 
forearms, forehead, and cheeks, which began as red lymphan- 
gitic plaques on which vesicles formed and coalesced into bullae. 
These dried into crusts and shelled off in a week without leav- 
ing any scar or mark. This is the rule, but sometimes they 
become suppurating and even gangrenous sores, and more or 
less scarring and even keloid will then result, as in the case of 
Neuberger,* an hysteric of twenty-six, who had scars and 
keloids from a previous attack. A month after she came into 
his clinic numerous blebs came over the right breast and 
clavicle. They kept on recurring, and then spread to the left 
breast and arm. The bullae were clear yellow, and had a pale 
red wheal-like margin. After some days they dried into easily 
detachable yellowish-green crusts, beneath which were suppu- 
rating fetid ulcers. As they slowly ciatrized, keloids devel- 
oped. Instead of blebs, necrotic areas, as if the skin had been 
cauterized, sometimes appeared. The eruption recurred per- 
sistently, affected the mouth and vulva, and fugitive erythema 
often came on the face. The patient emaciated and died in 
three months from the onset. There were no peripheral nerve 
changes, but syringomyelia was found, of which there were no 
diagnostic symptoms during life. He compares his case with 
Doutrelepont's well-known case (vide Hysterical Gangrene), 
and with Kaposi's zoster gangraenosus. 

Pemphigus Virginum, or Pemphigus of girls (Hardy), 
Pemphigus Chloroticus (Tommasoli). \ Hardy described a 
vesiculo-bullous eruption in young and generally chlorotic 
girls in which the bullae developed on elongated or oval red 
plaques of one to three centimeters. The vesicles soon burst 
and dry into a thin yellowish crust. They may be very numer- 
ous and cover a whole limb. The affection, by a succession of 
fresh lesions, may last for several months, and Tommasoli re- 
gards it as quite different from P. hystericus and considers it 
due to an auto-toxin. 

* Transactions Germ. Derm. Soc. at Leiftsi", 1891. Abs. Brit. Jour. 
Derm., vol. vi. (1893), p. 60. 

f " Du Pemphigus des jetmes filles et du P. hystericus," Tommasoli, 
Jour. Maladies Cutanees, vol. vi. (1895), p. 449. 



PEMPHIGUS. 299 

There only remain four definite main varieties: pemphigus 
acutus; pemphigus chronicus seu vulgaris; pemphigus folia- 
ceus, which is always chronic; and pemphigus vegetans. A 
few minor varieties will also be noticed. 

Acute Pemphigus is much rarer than the chronic form, and 
Hebra even denied its existence; but though, doubtless, cases 
have been called acute pemphigus in which the bullae were 
merely an accidental feature, as in bullous erythema, varicella 
bullosa, etc., there are other cases which run their course in 
from one to six weeks, often with a fatal termination, and are 
universally regarded as pemphigus; though etiologically they 
are probably separate affections. 

Pernet,* in publishing a fatal case observed by him in my 
clinic, collected sixteen other cases (eight fatal), and found 
that, while three were due to bites of animals, the others oc- 
curred either in butchers (eight) or those whose occupations 
rendered them liable to animal septic poisons, and in many of 
them a distinct history of a wound was obtained. In several 
the first bulla was at the wound and was mistaken for a whit- 
low. In a considerable number of cases the temperature has 
been over 104 and with shivering nausea and other febrile 
symptoms. In these cases bullae from a pea to a hen's egg in 
size, and many of them hemorrhagic, come out by the score 
every day, and affect the tongue, mouth, eyelids, and other 
mucous orifices. There is often very extensive denudation of 
the epidermis from coalescence of the crowded bullae, especially 
at the flexures and points of pressure, and the stench of the 
sodden decaying epidermis is almost insupportable. In the 
worst cases the patient becomes delirious and dies in a typhoid 
state in from one to three weeks, often with albuminuria, as in 
Senfleben and Duckworth's f cases; the latter died in nine days, 
one-sixth of the whole body surface being affected. The prog- 
nosis is largely determined by the acuteness of development of 
the bullae, and the extent of body surface involved. 

Even where recovery takes place, as in Southey's \ case, aet 

* " Acute Pemphigus," by G. Pernet and W. Bulloch. Brit. four. 
Derm., vol. viii.. May, 1896, p. 157, with full references and bacteriology. 
\ St. Bari.'s Hosp. Rep., vol. xx. (1884), p. 41. 
% Clin. Soc. Trans., vol. viii., p. 179. 



300 DISEASES OF THE SKIN. 

nineteen, and Payne's, * set. seventy, the patient was brought 
to death's door. Allen's \ case, though acute in development, 
only affected the upper part of the body, and that not severely; 
it was preceded by itching, chilliness, nausea, malaise, and was, 
as usual, accompanied by' fever. 

Acute pemphigus in children is much more common, often 
less severe, and probably of different etiology. Diarrhea, sick- 
ness, and fever are usual antecedents and concomitants; its 
danger is measured by the extent of skin involved in a short 
time; it has supervened after the exanthemata, such as scarla- 
tina and measles. 

Bulloch examined the fluid of an unruptured bulla both in 
Pernet's and Hadley's case, and found a diplococcus rather 
larger than the gonococcus. It appears to be the same organ- 
ism as that described by Demme and Bleibtreu in their cases, 
and is probably the pathogenic organism. 

P. Chronicus (the specific title " vulgaris " is generally 
dropped) is the usual form. In a typical case hemispherical 
or oval bullae, with tense walls and translucent contents, de- 
velop bilaterally, and to some extent symmetrically, upon 
almost any part of the body; but they are generally most 
abundant upon the lower part of the face and trunk, and on the 
limbs. They come out in crops at intervals of a few days, scat- 
tered singly, or irregularly grouped, vary in number from two 
or three to several scores, and are vesicular from the first, 
though there may be slight punctiform vascularity of the sur- 
face, preceding the pin's-head-sized vesicle, which, rapidly en- 
larging, attains its full size in a few hours. The majority are 
from a quarter to one inch in diameter, but the extremes are 
from an eighth to two or three inches in their greatest diameter. 
The largest are generally formed by coalescence with neighbor- 
ing bullae, and are therefore irregular in outline. The bulla 
projects abruptly and prominently above the normal skin, 

* St. T/iomas's Hosp. Rep., vol. xii. 

\Jour. Cut. and Gen.-Ur. Dz's., vol. vi. (1888), p. 121, with colored 
plate and reference to two other cases. 

Hallopeau and Levi publish the case of a butcher, set. sixty, who 
recovered. Bullae ceased to come out after the second week. Annates 
de Derm., vol. viii. (1897), p. 61. 



PEMPHIGUS. 



301 



forming an oval or roundish tense-walled bleb, the fluid in 
which is at first perfectly clear, and there is no areola; but the 
contents soon become turbid from the increased number of 
leukocytes, and a narrow red areola forms as the purulent 
character increases. The effused fluid is soon absorbed, leav- 
ing only a thin scab on its site, formed by the dried cover of 
the bulla, or, if the latter ruptures, a superficial excoriation 
may ensue, and when this has healed, or when the scab falls off, 
a red stain is left, which after a time may become pigmented. 
The duration of each bulla is a matter of a few days; but the 
disease as a whole, by the formation of fresh crops, lasts from 
six weeks to as many months, the fresh bullae eventually be- 
coming fewer and smaller. Though there may be only one at- 
tack, as a rule the disease recurs several times at intervals of a 
few months or a year, and then ceases altogether. 

General Symptoms. — In a well-marked case, especially in chil- 
dren and old people, the eruption may be preceded by chilliness, 
nausea, and even vomiting, pyrexia amounting to a rise of two 
or three degrees, and other febrile symptoms, which often re- 
cur with each fresh crop of eruption; and when the excoriated 
surface is large, and the bullae numerous and come out at short 
intervals, there may be severe prostration from the sleepless- 
ness, pyrexia, and anorexia, and even death may occur in acute 
cases, within two or three weeks from the onset of the eruption. 
On the other hand, in most adults, and where the bullae are 
few and in moderate numbers, there may be little or no consti- 
tutional disturbance, but only local subjective symptoms, such 
as a feeling of heat or tension. Where the bullae are most 
abundant and crowded, or if the pus is confined by the crusts, 
the lymphatics and glands of the neighborhood become in- 
flamed, but there is only actual pain and smarting when the 
corium has been exposed by the too rough removal of the 
crusts, by scratching or otherwise. 

Variations. — Great differences are produced in the clinical 
aspect of pemphigus, owing to the variation in number, size, 
and contents of the bullae, the condition of the skin beneath 
their covering, the intervals between the evolution of the crops 
or of the disease as a whole, and the constitutional or subjective 
symptoms. 

In rare instances the disease mav be in a sense local. One 



3 o2 DISEASES OF THE SKIN. 

or two large bullae appear at a time, erratically as regards their 
position, but with rather a tendency to appear where the circu- 
lation is feeble, such as on the toes, fingers, or nose, or on the 
ankle or wrist, local venous congestion sometimes preceding 
the bullae. This is spoken of as P. solitarius or localis, and is 
seen chiefly in the aged and debilitated. I have, however, seen 
it on the legs only of a young woman and on a man of fifty- 
four. 

In a few cases I have seen it limited to the face and back of 
the hands. In one, a boy of four, a bulla formed under each 
nail, detaching it from its bed, except at the base. Pick * 
records a case of an hysterical woman in whom it was uni- 
lateral, the whole right side being affected; and H. Neumann 
of Potsdam records the case of a boy of nine in which bullae 
and purpuric lesions were on the left side only, following diph- 
theria, measles, and severe otitis media, and preceding subacute 
suppurative polymyositis. 

When they appear in continuous crops and in enormous 
numbers it is P. diutinus. In this form scarcely a part of the 
body is free from eruption, and life is endangered. 

Willan, Hebra, and Kaposi use the same term for cases 
where the relapses follow closely or even almost continuously 
on each other, instead of at the usual intervals of a year or so. 
Again, it has been used for cases where the bullae continue to 
appear for many years, or even for the whole life, but only one 
or a very few at a time. Obviously, it is best to drop alto- 
gether the use of a term the meaning of which varies according 
to the view of the individual who employs it. 

The contents may be purulent at an early stage, or yellow 
lymph may form on the base (P. diphtheriticus), or the inflam- 
matory process may be still more intense and superficial, or a 
deep slough may form (P. gangraenosus) — this generally 
occurs in children only, and will be again alluded to; or there 
may be hemorrhage into the bullae, varying in amount from 
enough to impart a mere pink tint to the serum, up to black 
(P. haemorrhagicus, or purpura bullosa). f 

* Quoted Arch. Derm., vol. vi., p. 283, from Wien. med. Presse, 1880, 
p. 183. 

fin 1898 a male infant, set. one month, was brought to the U. C. H. 
The eruption began four days afterbirth with two spots on the chest, and 



PEMPHIGUS. 



3°3 



In P. Pruriginosus, as the name indicates, severe itching is 
the prominent symptom, and the consequent scratching pro- 
duces, as usual, considerable modifications in the eruption; the 
contents of the bullae soon become purulent; after a time 
wheals appear, and the bullae sometimes develop on the 
wheals. 

When the itching is very intense the bullae frequently abort, 
the earliest vesicles being torn open by the nails before they 
can develop fully. When the disease has lasted for years the 
other phenomena of the long-scratched skin are evolved, such 
as eczema, ecthyma, or impetigo contagiosa, pigmentation dif- 
fuse or in streaks or spots, and thickening with dryness of the 
skin. The loss of sleep and the constant worry produce con- 
siderable nervous depression, and may even wear the patient 
out; and all the severe forms may have a fatal issue, either 
directly from exhaustion, or indirectly from intercurrent dis- 
ease, to which the vital exhaustion renders them vulnerable. 
These severe forms have therefore been classed by some au- 
thors as forms of P. malignus, as opposed to the typical P. 
vulgaris, which has been called P. benignus, but these terms 
are superfluous. The P. pruriginosus of Hardy is the affection 
described under Dermatitis Herpetiformis, while Hebra and 
Kaposi call it P. hystericus. Many modern authors consider 
that all cases of pemphigus with extreme itching are referable 
to dermatitis herpetiformis; but, while this is true for many 
of the older cases, I am convinced there is a residue which is 
distinct from dermatitis herpetiformis, and really belongs to 
pemphigus. 

had been coming out ever since. None of them had quite gone, as they 
broke and filled again, discharging blood. All regions, including the 
palms and soles, were involved, but not the finger-ends, but there had 
been some lesions in the mouth. They were vesicular, from a millet to 
a pea in size, of a bright mulberry to a dark purple hue, and they stood out 
conspicuously from there being a zone of pale skin round them. The 
child was well nourished and not cachectic-looking, but it died a few 
days after admission, and the right pleura was found to be full of pus, 
with small abscesses in the liver and infarcts in the spleen. Nothing to 
show how the septic condition arose; the parents were not poor, and the 
hygienic surroundings were good. 

A well-marked case in an adult came to me with large hemorrhagic 
bullae on the soles, a few days before his death from chronic alcoholism, 
albuminuria, and hypertrophic cirrhosis of the liver. 



304 DISEASES OF THE SKIN. 

Pemphigus circinatus cases have been described by vari- 
ous observers, but they differ considerably in their features. 
C. W. Allen * of New York recorded a case in a woman, aet. 
forty-five, in whom bullae arose from the center of a well-defined 
circinate erythematous base which was much larger than the 
bulla. In some of them vesicles developed on the circinate 
border, either discrete or confluent. In some places extensive 
denuded patches, more or less crusted over, were formed by 
coalescence of many bullae. Some of the bullae arose inde- 
pendently of the erythema. Penrose and myself have met with 
very similar cases in children. In my case the skin was covered 
with abruptly margined erythematous rings, with a bulla in the 
center, which pulsated, growing paler and then brighter with 
each heart-beat. Some lesions presented vesicles in a ring on 
the periphery of a red patch, but both cases were different to 
any case of dermatitis herpetiformis; and the mother said the 
rings were the sequel of the bullae, but the appearance of bullae 
in the center and periphery of the ringed patch was against this. 

Some of the cases published as circinate pemphigus are really 
the vesicular form of erythema iris, and some are, no doubt, 
cases of dermatitis herpetiformis. 

The following is, as far as I know, a unique circinate form. 
A lady, aet. forty, who had had two previous attacks in eighteen 
months, began another with bullae of the ordinary pemphigus 
type, which was controlled by salicin. About a fortnight after 
leaving off the medicine a fresh outbreak occurred resembling 
the two previous attacks. The whole of the back, the upper 
segments of the limbs, and to a less extent the rest of the body, 
were covered with circles from a half to two inches in diameter, 
while larger gyrate areas were formed by several rings uniting. 
The border was at first one-sixteenth of an inch, and later in- 
creased to one-fourth and one-third of an inch, surmounted by 
a vesicular portion which formed a continuous ring, and was 
not made up of separate coalesced vesicles. Each circle began 
as a pin's head or smaller vesicle, on a red very slightly raised 
base, and then spread peripherally. Very severe itching, com- 
ing on in paroxysms, accompanied the eruption. f The pa- 

*Jour. Cut, and Gen.- Ur. Dis., vol. viii. (1890), p. 471. 
f Compare this case with those of Hallopeau's dermatitis herpetiformis 
en cocardes, Plate X., St. Louis Atlas, and Liddell and Wende's cases. 



PEMPHIGUS. 305 

tient was a delicate woman who had suffered from endo- 
metritis. 

Pemphigus of Mucous Membranes. All forms of pemphi- 
gus may attack the mucous membrane of the mouth, and 
less frequently that of other cavities, pharynx, larynx, nose, 
stomach, and eye. It is a striking feature of P. vegetans. 
There is a special form in which the mucous membranes are 
either exclusively involved or the skin lesions are comparatively 
trivial. Owing to the adhesions of the adjacent raw surfaces 
its local effects may be very serious; thus, in the conjunctiva it 
leads to adhesion of the ocular and palpebral conjunctiva, which 
von Graefe called " essential shrinking of the conjunctiva." * 
Whether this is due to pemphigus only is a disputed point. It 
has occurred at all ages from fourteen months to seventy-six 
years; some have, and some have not, had bullae on the skin. 
I have seen several cases, one in a German gentleman who had 
in addition pemphigus of the palate and pharynx; it led to ad- 
hesions closing the posterior nares and producing loss of smell 
and taste; the laryngeal and nasal mucous membranes were 
also involved, and he sometimes had bullae on the skin. The 
disease had been going on for years, f He eventually got well, 
apparently from the administration for a long period of small 
doses of arsenic. Large doses exerted no influence. 

Charters Symonds reports similar general involvement of 
mucous membranes, but the skin was free.]; 

Many cases are uninfluenced by treatment, and ultimately 
lead to the death of the patient from marasmus; in a few gen- 
eral pemphigus has supervened, while a case under Colcott 
Fox commenced as a general pemphigus, and the conjunctivae 
were not attacked for some years. 

Complications and Sequela. — Great thickening of the horny 
layer of the palms and soles (keratosis or tylosis) is occasionally 

*M. Morris and L. Roberts published a case, with colored plate and 
general summary and bibliography to date, in Brit. Jour. Derm., vol. i. 
(1889), p. 175. Also Ed. Pergens' " Pemphigus des Auges, 1901," with 
analysis and full bibliography to date. 

fD., p. 251, private notes. The skin lesions are depicted in my Atlas, 
Plate XII., Figs. 2 and 3. They are quite small, but when they first ap- 
peared were the size of a hazelnut. 

% Clin. Soc. Trans., vol. xxiii., 1890. 



306 DISEASES OF THE SKIN. 

seen in pemphigus, as in a case of P. pruriginosus related by 
myself (see Keratosis Palmae), by Besnier and by Quinquaud 
in a P. foliaceus, and also by Besnier and Brocq in dermatitis 
herpetiformis.* The possibility of the hyperkeratosis being 
due to arsenic must always be borne in mind, as it has nearly 
always been given in these bullous eruptions, but Besnier has 
seen it when no arsenic had been given. 

Groups of milium-like nodules, really solid epidermic cysts, 
are sometimes produced on the site of the bullae, but I do not 
believe, as some do, that they ever come before the bullae. I 
have seen, in what was otherwise an ordinary pemphigus, con- 
vex f erythematous swellings left after the drying up of the 
bullae. 

Pemphigus Foliaceus J differs so much from the other forms 
that if it was not that P. vulgaris sometimes lapses into this 
condition it would appear to be a separate disease. It was first 
described by Cazenave in 1844. It is very rare, occurring 
about once in five thousand cases of skin disease, and six cases 
(five women and one man) have come under my notice. It is 
one of the few kinds of dermatitis which have a universal dis- 
tribution, and is characterized by the formation of flaccid bullae, 
which speedily rupture and discharge their opaque contents, 
leaving an inflamed, excoriated, and fissured surface behind. 

The disease may be primary, the bullae showing the P. folia- 
ceus characteristics from the first, or they may develop from 
what appears to be an ordinary, though perhaps severe, chronic 
pemphigus, the bullae changing their character. It has also 
developed from a dermatitis herpetiformis (Hallopeau) and a 
general exfoliative dermatitis of Wilson (Pringle, Mracek, etc.). 

Symptoms. — The bullae are quite flaccid, the fluid only just 
raising the epidermis irregularly in circumscribed patches from 

* Brocq thought my case was a dermatitis herpetiformis, because the 
patient had red patches on the trunk when first seen; but these marked 
the site of former bullae, and were not the erythema characteristic of D. 
herpetiformis. It is reported in Brit. Jour. Derm., vol. iii. (1891), p. 170, 
and at Figs. 3 and 4, Plate XLIV., of my Atlas. 

f Mary S., set. forty-four, U. C. H. I once saw an unruptured bulla on 
the edge of her tongue. 

% Author's Atlas, Plate XVIII.; Sydenham Society's Atlas, Plate 
XLVII. 



PEMPHIGUS. 307 

the subjacent parts, or, if the amount of fluid is somewhat 
greater, it bags into the lower part of the bulla. The contents 
are turbid almost from the first, and soon become distinctly 
purulent. The bulla soon ruptures by the extension of the 
peripheral detachment of the epidermis, but instead of drying 
up the corium remains moist and exposed between the bulla 
coverings, which, except at the edges, are adherent, but easily 
detachable, and the under-surface is moistened with sero-pus 
and an evil-smelling serum, which gives a faint nauseous odor 
to the whole room. 

The epidermis splits into variously sized lamellae, and the 
separation of these flabby crusts from each other leaves an 
interval of red corium, which exudes like an eczema, and im- 
parts an irregularly tesselated appearance to the affected sur- 
face. At first only a few square inches are attacked, but gradu- 
ally the disease spreads, until in the course of weeks, months, 
or years, the whole body surface is affected, and there is literally 
not a sound spot anywhere, though bullae seldom form on the 
palms or soles, the skin there being thickened, brittle, and easily 
fissured. The mucous membrane of the mouth and throat may 
be denuded of epithelium in patches, and the nails are thin, 
curved laterally and longitudinally, much furrowed trans- 
versely, and may be thrown off. The hair falls out, leaving 
only thin, small tufts; the eyelids become ectropic; and emacia- 
tion is extreme in some cases. When the disease is universal 
the aspect varies in different parts ; where the exudation * is 
great, relatively thick flat crusts are formed, partly epithelial, 
partly from dried exudation; and when thrown off in large 
patches, the red weeping surface looks like an eczema rubrum. 
A general papillomatosis was *observed by Besnier. Where 
there is less exudation the crusts are thin and epidermal, sepa- 
rable into their component lamellae, and of a dirty buff color. 

Nikolsky pointed out that there was a diminution of the ad- 
hesion between the horny and deeper layers of the epidermis, 
and Dubreuilh considers that this sign is present in the whole 
of the pemphigus group. Xaserow asserts that this disunion 
of the stratum corneum from the stratum lucidum exists over 

* Hallopeau describes a case of this kind as a new variety, but the form 
has been recognized for a long time and was described in a previous 
edition. Hallopeau, Amiales de Derm., vol. ii. (1901), p. 1094. 



3 o8 DISEASES OF THE SKIN. 

the whole skin even where there are no bullae, and considers it 
diagnostic of P. foliaceus. In an advanced case the formation 
of the bullae is only to be observed by daily watching, as they 
form either where the corium has skinned over temporarily or 
underneath the thin crusts, and rupture in a few hours. 

There is a feeling of stiffness and tension of the skin where 
the epidermis has dried. There is not much itching as a rule, 
but it is sometimes severe and paroxysmal, and considerable 
smarting and soreness, owing to the movements of the patient 
rubbing off the loose crusts, or splitting the skin and exposing 
the corium afresh to the air. 

After the disease has lasted for a considerable time some 
have febrile symptoms, either intermittent or continuous, but 
usually the temperature is normal, and may continue so 
throughout. This was so in two of my cases, one of seven 
and a half, the other of two years' duration, in which the tem- 
perature while under observation never rose above ioo° F. until 
fatal pneumonia set in. The disease is often of many years' 
duration, and the general health may be good at first, but ulti- 
mately it breaks down. The patient wastes, is greatly pros- 
trated, sinks into a typhoid state with low delirium, or falls an 
easy prey to some intercurrent malady, most frequently of the 
chest * or kidneys. It runs its course, however, with exacerba- 
tions and remissions. During the latter some parts of the 
skin heal up entirely, and there may be general improvement, 
deluding both doctor and patient sometimes into the hope of 
a recovery, which is soon dispelled by a fresh outbreak of bullae. 

In one of my cases, a woman aged thirty-nine, some of the 
remissions lasted two or three weeks, but they were seldom 
complete. In this case a severe cold preceded an extensive 
outbreak of ordinary pemphigus, which lasted over two years. 
Then she had " a severe influenza," and the bullae came out 
more extensively than ever and assumed the character of P. 
foliaceus; her health then broke down, and she felt so ill that 
she had to give up her employment. The rash was always 
worse at the catamenial period, which had ceased two years 
before admission. 

*In Martha W., set. thirty-two (P. M.), there was double pneumonia, 
pleurisy, and pericarditis. No visible nervous changes in the cord, 
medulla, or brain, either macro- or microscopically. 



PEMPHIGUS. 309 

The examination of the urine for twenty-three consecutive 
days was made by Dr. Halliburton, then my clinical clerk, and 
gave the following results. The daily average quantity of 
urine was 868 c. c. (31 ounces), the average quantity of urea 
12.14 grams (187 grains), ranging from 8.58 to 14.98 grams, 
and the quantity of phosphates was 1.966 grains (30 grains). 
The diet was kept as uniform as possible. The great diminu- 
tion in urea was partly due, no doubt, to her being at absolute 
rest in bed. Her weight was 129 pounds. 

In a case of Hallopeau's * of eight years' duration, in whom 
osteomalacia developed, there was half the normal quantity of 
urea, three times more than the mean normal of phosphates, 
and five times more than the normal of phosphate of lime. 

I am not aware of any typical case occurring in childhood, 
Vincent Hall's f case being of a different character. A boy of 
eleven years was suddenly seized with redness and swelling of 
the face, then bullae appeared and in two days covered the face, 
which became a mass of scabs. This was followed by their 
development over the whole body surface, and within a few 
days the skin exfoliated in masses four to six inches square at 
the rate of a dustpanful a day. Although delirious for a few 
days he had a ravenous appetite for solid food, and was quite 
well in twenty-eight days from the onset. Although there 
were bullae and exfoliation enough, this was not true P. folia- 
ceus. So, too, in Hellier's case % of an apparently healthy 
new-born infant, in whom on the eleventh day redness of the 
skin was followed on the next with large flaccid bullae with 
serous contents. They rapidly extended over the trunk with 
extensive denudation of the surface, and the child died on the 
fourth day of disease. It was probably only a severe P. 
neonatorum. 

Etiology. — Very little is known on this head. That chills 
have a distinct influence in some instances in the production 
of P. foliaceus is pretty generally acknowledged, and I have 
already given an example of such a circumstance. Schwim- 

* Annales de Derm., etc., vol. xi. (1898), p. 979. 

f A case of pemphigus foliaceus, recovery. Brit. Med. Jour., July 11, 
1896. 

:}: Pemphigus foliaceus in the newborn. Brit. Jour. Derm., vol. xi. 
(1899), p. 18. 



3 io DISEASES OF THE SKIN. 

mer also gives a well-marked case of it, and there are many 
others on record. It has already been pointed out that some 
cases of persistent P. vulgaris, dermatitis herpetiformis, pity- 
riasis rubra, and other forms of dermatitis, lapse into P. 
foliaceus. 

Violent mental emotion immediately preceded a case under 
Hallopeau. 

Du Mesnil de Rochemont * records a case clearly traceable 
to a thorn in the thumb producing a whitlow and lymphangitis 
wtih multiple suppurations along the limb. Shortly after 
pemphigus developed, and was limited to the same limb; then 
red spots gradually spread over the whole body, and after some 
time pemphigus foliaceus was fully and typically established. 

The Histology of P. foliaceus has been investigated by Unna, Nikol- 
sky, Lered.de, etc., with general agreement. There is great elongation 
of the papillae and interpapillary cones, and the rete over the papillae 
is much thinner. The epithelial cells in the hypertrophied cones are 
swollen, softened, and edematous, and the spaces between them are en- 
larged and contain numerous migratory cells. There is great blood and 
lymphatic vascular dilatation; the connective tissue is swollen, and there 
are abundant migratory cells all through the derm and hypoderm. 

In the blood Leredde found, in two cases, diminution of red corpuscles, 
increase and alterations of white corpuscles, diminution of hemoglobin, 
and considerable increase of eosinophile cells. 

These blood changes are similar to those in P. vegetans and dermatitis 
herpetiformis, and bring all these diseases into line, Leredde thinks, and 
he calls them " hematodermites " — i. e., blood diseases, to which the 
cutaneous lesions are secondary. He thinks that various toxins act on 
the bone marrow which charge the blood serum with substances which 
excite the skin lesions. He discusses and rejects Neusser's theory that 
the skin changes determine the formation of eosinophile elements in the 
skin, whence they are absorbed into the blood, and that of Ehrlich and 
Lazarus, that the skin lesions produce a chemiotactic substance which 
irritates the bone marrow and so produces eosinophilia. 

Diagnosis. — P. foliaceus has to be distinguished from other 
forms of universal dermatitis, such as general eczema, pityriasis 
rubra, lichen acuminatus universalis. 

It resembles a general eczema rubrnm very closely, but in P. 
foliaceus the crusts are mainly epithelial and of large size, while 
in eczema they are chiefly composed of dried exudation and not 
often large. Although the exudation may be continuous, it is 
much less than in eczema of corresponding severity. Moreover, 

* Arch. f. Derm. u. Syfih., vol. xxx. (1895), p. 103. Good abs. in 
Annales, vol. vi. (1895), p. 142. 



PEMPHIGUS. 



3ii 



a universal distribution of eczema is extremely rare, while it is 
the rule in P. foliaceus, if it has lasted long. Whenever, there- 
fore, what appears to be a universal eczema is present, the 
probability of its being P. foliaceus should be borne in mind, 
and daily observation will soon establish the presence or ab- 
sence of the characteristic large flaccid bullae of the P. foliaceus 
eruption, and all doubt is then set at rest. The existence of 
the bullae and the presence of discharge will prevent confusion 
with pityriasis rubra or lichen acuminatus, which are both dry 
diseases, though the resemblance is great in certain parts when 
the bullae have temporarily ceased to be evolved, but in pity- 
riasis rubra the scales are thin and papery, while in P. foliaceus 
they are comparatively thick. In lichen acuminatus there is 
great thickening of the skin and moderate scaliness, and the 
characteristic papules are always to be found in some part or 
other. P. vegetans differs from P. foliaceus in the ulceration, 
the papillary hypertrophy, the mouth affection, and the ab- 
sence of universality. 

The prognosis and treatment are given with those of other 
forms. 

Pemphigus Vegetans.* Neumann \ was the first in 1886 to 
identify the disease as a form of pemphigus, but the affection 
had been previously described by Kaposi \ in 1869 and again 
in 1873 as syphilis vegetans, while Auspitz, also in 1869, de- 
scribed two cases as herpes vegetans. I met with a typical in- 
stance in 1887, then the only one in England recognized as 
belonging to this category, though Hutchinson appears to have 
seen several cases before this, but was unaware that it had been 
already described by German observers. Some of Hutchin- 
son's were of a mild type, the mouth being chiefly affected, and 
the skin only a very little. These recovered under treatment, 
and it is open to discussion as to whether they were really cases 
of P. vegetans. Three typical cases have come under my 
notice since 1887, § one through' the kindness of Mr. Hutchin- 

* Author's Atlas, Plate XIX. 

f Viertelj.f. Derm. it. Syftk., vol. xii., 1886, with plates and references. 

% Die Syphilis der Haut, 1873, Plates LXIII. and LXIV. 

§ Published in Med. Chir. Trans., vol. lxxii. (1889), p. 233, with bibli- 
ography up to date. Since then cases have been published by Haslund 
of Copenhagen, in Danish; by Muller of Hamburg, two cases, Monatsh. 



3 i2 DISEASES OF THE SKIN. 

son. This patient had been under Kobner in 1890. He had 
suffered from sore mouth since 1885, and bullae first appeared 
in October, 1890. Kobner scraped and cauterized the growths 
in the inguinal regions, applied tincture of iodin, and gave 
arsenic extensively, and pronounced him cured in March, 1891. 
Except for slight relapses in the mouth he remained well in 
1892 and 1893, but in 1894 bullae and vegetations started again, 
he came under Hutchinson in August, and died in April, 1895. 
The case is unique in its duration, apparent cure, and fatal re- 
lapse. Although some sixty cases are on record, P. vegetans 
is fortunately very rare, as fully developed cases are not only 
almost uniformly fatal, but entail more suffering than any other 
form of skin disease.* 

Symptoms. — Without any preceding illness or any apparent 
cause the first symptom in the great majority of cases is pain 
on eating and swallowing, and on examining the mouth the 
mucous membrane is white and more or less detached, or if 
very recently formed there may be an unruptured bulla. Any 
part of the mouth, tongue, palate, pharynx, and larynx may be 
affected, and at a later period the nares,f conjunctivae, or vulva 
also. 

A few cases have commenced in other parts; in one of mine 

f. prakt. Derm., vol. xi., p. 427, adopting Unna's new name, erythema 
bullosum vegetans. He also collected twenty-four cases, and read a 
paper on them at the Bremen reunion of physicians and surgeons in 
1890. A case from Russia is reported in Sajous' Satellite. Marianelli 
published an Italian case; abs. in Viertelj. f. Derm. u. Syph., vol. xxii. 
(1890), p. 236. Nevins Hyde reports a case from America, still alive at 
time of report, in Jour. Cut. and Gen.-Ur. Dis., vol. ix. (1891), pp. 412, 
459 He found and cultivated a bacillus and coccus from an unruptured 
bulla, but without any proved significance. In the same volume, p. 332, 
is a case of P. foliaceus malignus, by Munro and Schwartz, which reads 
like P. vegetans, except that papillomata are not mentioned; in Lancet. 
May 23, 1 89 1, Pagan Lowe of Bath reports a case; and in Brit. Med. 
Jour., June 9, 18Q4, F. Cuthbert reports a case under the name of P. 
foliaceus. P. vegetans, therefore, is clearly a very definite and cosmo- 
politan clinical entity. 

* Kobner published this case with two others and some valuable ob- 
servations in Deutsches Archiv f. Clin. Med., vol. liii. (1894), and vol. 
lvii., p. 63, with two more cases. Full French resume in Annates de 
Der?n., vol. v. (1894), p. 890; vol. vii. (1897), p. 816; and Hutchinson pub- 
lished the sequel and analysis of the history in Archives of Surg., vol. 
viii. p. 129, and colored Plate 156, vol. ix., p. 30. 

f In a case of Neumann's the nares were the first part attacked. 



PEMPHIGUS. 



313 



bullae on the chest were the first signs, and the axillary border, 
abdomen, and genital region have been the starting points in 
some cases. 

After a variable interval of days or weeks, occasionally much 
longer, bullae of ordinary appearance, either singly or in groups, 
come out on the hands, feet, axillae, and groins, and subse- 
quently on other parts of the body. But instead of drying up 
as usual they remain excoriated, or ulcerate deeply and some- 
times extend serpiginously, while in the folds, such as the 
groins and axillae, they fungate into papillary excrescences, 
which may project half an inch above the surface, secrete a 
viscid offensive fluid, and closely resemble condylomata. 
They may also occur in other regions, and in a few cases quite 
early in the disease. 

Some of the excoriations may heal in the center, or alto- 
gether, leaving pigmentation or papillary incrustation, but most 
of them remain as raw surfaces, especially where there is press- 
ure, such as on the back of the head, shoulders, and scrotum; 
numerous small bullae and vesicles may often be observed 
round some of the excoriations, and form one mode of their ex- 
tension. The matrix of some of the nails is not infrequently at- 
tacked, producing a condition resembling onychia maligna. 
Fresh crops of bullae lead to more and more denudation of the 
skin, the whole back becoming raw and sodden in some cases; 
nutrition is interfered with, owing to the extent of surface in- 
volved, and from the condition of the oral mucous membrane, 
which interferes with the digestion of food; and in some cases, 
the great loss of albumin and the presence of diarrhea. The. 
sensory symptoms are those of burning and itching, but, except 
in the mouth, pain is only experienced when changing the 
dressings, which is absolutely necessary owing to the penetrat- 
ing and insupportably nauseous fetor of the decaying epi- 
thelium. Tremor of the muscles even in repose is often to be 
observed, according to Herxheimer, when the skin is exten- 
sively involved. The disease is invariably fatal in from three 
to twelve months in most cases, either from exhaustion or from 
intercurrent disease. The temperature is often raised, but 
seldom to more than 102 F. Examination of the blood * has 

* In Dubreuilh's case 42 per cent, eosinophile cells, 44 leukocytes, 14 
lymphocytes. In Neumann's case 16,000 white to 4,100,000 red corpuscles, 



3H DISEASES OF THE SKIN. 

not yielded any practical results. There appear to be cases in 
which there are mouth lesions while the skin is not at all in- 
volved; such cases often recover under treatment, but while 
some of them are inchoate P. vegetans, others have possibly 
been erroneously diagnosed. 

Hutchinson asserts that vegetations are exceptional; while I 
should admit that they are not absolutely essential, as they may 
cease, or be removed by treatment, and possibly never be 
present at all sometimes, I should speak with diffidence of any 
case in which they were entirely absent,* unless the case ran an 
unusually short course, as in Stopford Taylor's case.f More 
or less papillomatous development has been occasionally ob- 
served in other forms of pemphigus, such as P. foliaceus, and 
also in dermatitis herpetiformis, but this is an accidental com- 
plication common to many forms of dermatitis, and does not 
bring them into relation with the well-defined morbid condi- 
tion described, in which vegetation is only one very prominent 
symptom amongst others equally important. 

Hallopeau \ has described five cases of a vegetating affec- 
tion which he has finally called Pyodermite vegetante. It 

an excess of eosinophile cells, and 85 per cent, hemoglobin. In the Danlos 
Hudelo case only 6 per cent, eosinophile cells; lymphocytes, 14 per cent. 

* A man, set. thirty-six, came to U. C. H. in 1899, No. 346. His disease 
began with conjunctivitis, three days after cleaning out a stable drain; 
three days later the mouth was attacked, and a greater part denuded of 
its mucous membrane; bullae came on the genitalia. The bullae were 
small and came out also in various parts of the body, but not in the axillae 
and groins, and there were no vegetations. He died in three months 
from the onset with high temperature (104 F.) toward the end. 
Neither the blood nor the bullae yielded anything to cultivation. P. M. — 
There were no visceral changes, the principal ones being about the 
mouth and genitals. 

f Two fatal cases of pemphigus, Brit. Jour. Derm., vol. vi. (1894), p. 
177; also a case by Filaretopoulo, fatal in eight days, Mai. Cut., vol. viii. 
(1896), p. 556. 

\ Internal. Cong. Derm., Paris, 1889, Comptes Rendus. Archiv f. 
Derm. u. Syph., vol. xliii. (1898), p. 289, and vol. xlv., p. 323. Good abs. 
in Annates de Derm., etc., vol. x. (1899), p. 103. Colored Plate in Inter- 
national Atlas, 1890, p. vii., and in his treatise with Leredde. See also 
Hallopeau's description of the transition case and discussion thereon, 
Annates de Derm. vol. xi. (1898, p. 969, in which Darier considers that 
the histology supports Hallopeau's view, while Leredde is equally positive 
that the skin and blood lesions prove its identity with dermatitis herpeti- 
formis. In toe. cit., p. 1055, he gives a second note on the case. 



PEMPHIGUS. 



3*5 



differs a great deal from pemphigus vegetans, but he thinks it 
is really a pustular form of it, as he has seen the two forms in 
the same subject both successively and concurrently; otherwise 
from his description it appears to me more nearly allied to im- 
petigo herpetiformis than to P. vegetans, but it generally takes 
a more favorable course than either of those two lethal dis- 
eases. It is probably better to keep them apart until further 
connecting links are discovered. 

The eruption commences in the genital region or on the lips, 
mouth, or fingers, the primary lesion being a pustule on a red 
base. The pustules multiply in close groups, which extend 
peripherally with a prominent border, while the center dries up 
into crusts, which soon fall off and leave deep red staining. 
Xew pustules appear at intervals at the periphery of the plaque. 
Hallopeau considers that it extends by auto-inoculation and 
tends to spontaneous healing with deep stains, but not scars in 
most cases, but in some there have been indelible scars. The 
prognosis is relatively favorable, and local antiseptics are suffi- 
cient to cure it; it is, however, liable to return and take the 
more serious form of P. vegetans. 

" It differs from impetigo herpetiformis by the depth of the 
suppurations, by the absence of epidermic elevations from be- 
low in gyrate areas, by the absence of febrile reaction, and by 
its prognosis being less grave " (Hallopeau). 

Etiology. — Of this we know practically nothing. P. vegetans 
attacks both sexes, but women much more frequently than 
men. It occurs chiefly in middle-aged adults, and I am not 
aware of any case in a child or in extreme old age. 

In Haslund's case a whitlow from a splinter was followed 
six weeks later by superficial gangrene of the point of the fin- 
ger, and other whitlows followed on the fingers and toes; four 
days later bullae appeared in the mouth and on the labia majora, 
and that case followed its usual fatal course in seven months. 
Compare this with de Rochemont's case of P. foliaceus from a 
similar cause. 

Pathology. — It is still a moot point as to whether P. vegetans 
should be considered a special disease or a variant of pem- 
phigus. The constant presence of successive crops of bullae if 
the skin is attacked at all, and the fact that the individual symp- 
toms of P. vegetans may be present in different cases of P. vul- 



3 i6 DISEASES OF THE SKIN. 

garis, are strong arguments in favor of the pemphigus view. 
Unna's theory, that it is a form of erythema multiforme, and 
Tommasoli's, that it is malignant pemphigoid condylomatosis, 
meet with no support outside their immediate spheres of influ- 
ence. That the disease is due to a toxin acting on the nervous 
system is probable, but like Leredde's theory of hcmatodermites, 
unproved. That the pseudo-condylomatosis is due to micro- 
organisms, probably staphylococcus aureus, is shown by their 
disappearance under microbicide applications. 

Herxheimer * found cells of Langerhans in the epidermis, 
but, like most previous observers, failed to find any organisms 
which could be regarded as pathogenic. L. Waelsch found 
pseudo-diphtheria bacilli in two cases, which had a strong lethal 
effect on rabbits and guinea-pigs, but he could not prove that 
it was the pathogenic agent; at the same time, Behring's anti- 
toxin prevented death in animals while the control animals 
without it always died in thirty to sixty hours. Diphtheria 
antitoxin in Waelsch's second patient improved the condition 
of the mouth, but not of the rest of the body, and the patient 
died nine days after the injection with fever prostration and de- 
lirium. Leredde finds eosinophilia and other blood changes 
similar to P. foliaceus and dermatitis herpetiformis. In a man 
aged twenty-three f Westberg found changes in the columns of 
Goll and the posterior root zones in the cervical region; in the 
dorsal region there was diminution of nerve fibers and increase 
of the connective tissue in the white substance; there was 
atrophy of the anterior roots of the lumbar region. He 
ascribed these changes to a toxin producing parenchymatous 
degeneration and atrophy of the cord, such as occurs in many 
acute infectious maladies, and also at the same time the skin 
changes which are not secondary to the cord changes. 

Etiology. — There is much hypothesis, but very little ascer- 
tained fact, in the etiology of pemphigus generally. Sex has 
so little influence that while Kaposi, on the strength of 103 
cases, states that it is three times more frequent in males than 

*K. Herxheimer, Archiv f. Derm. u. Syfik., vol. xxxvi. (1896), p. 141, 
with table of twenty-seven published cases. Abs. in Annates, vol. vii. 
(1897), p. 817. Waelsch, loc. cit., vol. 1. (1899), p. 71; vol. Hi. (1900), Heft 3, 
and Monats/i., vol. xxxi. (1900), p. 31. 

f Abs. in Annates, vol. vii. (1896), p. 70. 



PEMPHIGUS. 



3i7 



in females, other statistics give the preponderance the other 
way. It is, however, certainly more frequent in children and 
infants than in adults, but the endemic form among infants has 
already been shown not to be true pemphigus. 

Hereditary * tendency occurs in epidermolysis only, but the 
occurrence of bullae on the site of local injuries may also be 
seen occasionally in other forms of pemphigus. 

The special etiology of acute, vegetant, and foliaceous pem- 
phigus has been given under their respective heads. 

Kirschner carefully observed a case of a man who, in his 
work, was subject to great vicissitudes of temperature. After 
a chill, when sweating, the secretion gradually ceased, and 
pemphigus developed, and was stopped when the sweat secre- 
tion was restored; other attacks were brought on by his resum- 
ing his work, and again stopped by sudorifics; finally the at- 
tacks ceased when he gave up his employment. 

In a severe case of Payne's worry and anxiety appeared to 
be a chief factor. 

Pathology. — Although falling far short of proof, the frequent 
association of nerve lesions with bullous eruptions is strongly 
in favor of the nervous system being, at least indirectly, respon- 
sible for the production of pemphigus, and this is to some ex- 
tent corroborated by the efficacy of arsenic in its treatment. 
What the nervous defect is it is impossible to do more than con- 
jecture, but it lies probably in the vaso-motor centers, and 
Schwimmer and others regarded it as a trophoneurosis. The 
more modern doctrine of toxins affecting the nerve centers has 
been almost proved for acute pemphigus, and is the most prob- 
able explanation for the more chronic forms. The exciting 
action of chills, demonstrable in a few cases, may be explained 
by the probable assumption that after a chilling of the surface 
there is in the reaction vascular dilatation and an absorption 
from the intestine of auto-toxins into the circulation. 

Hypothetic as these views are, others which regard the dis- 
ease as due to excess of ammonia in the blood (Bamberger), 
defective kidney elimination, etc., rest upon a much more slen- 
der basis. 

* Kaposi gives an instance in which a young man, his mother, sister, 
maternal uncle, and half his children had it, but this was also probably 
epidermolysis bullosa. 



318 DISEASES OF THE SKIN. 

Anatomy. — The following observations are limited to the bullae of the 
ordinary chronic pemphigus. Most authors regard the actual formation 
of the bulla as due to an inflammation of the papillary layer, with out- 
pouring of fluid from the vessels, but Auspitz calls it an acantholysis, or 
loosening of the prickle-cell layer, by the sudden escape of fluid from the 
vessels, destroying the young prickle cells and lifting up the epidermis 
as a whole. Any inflammatory phenomena, he thinks, are secondary. 

The anatomy of the bulla has been investigated by, among others, 
Haight, Hebra, Kaposi, and more recently, Kromeyer, Luithlen, Jarisch, 
and quite recently by Audry and Danlos, Dejerine and Leloir in France, 
Kreibich in Germany, and by myself, and the contents have been 
analyzed, with varying results, by several observers. 

The bullae have not all been taken from the same kind of case, but 
Audry and Danlos' * own observations and analysis of those of others 
show that even in the same patient all the bullae have not the same ana- 
tomical position, but may be: 

i. Developed between the horny layer and the stratum granulosum. 

2. Between the rete Malpighii and the cylindrical basal layer. 

3. The papillae may be quite bare, either by the whole epidermis being 
raised up or by secondary destruction of the epithelial elements which 
cover the papillae. 

They point out that the slight changes of the papillary layer, mainly 
vascular, show that there is no true dermatitis. In the most superficial 
vesicles the rete may be normal, and they come to the conclusion that 
the epithelial changes are only the most visible part of the effects of a 
general toxin, which also produces leukocytosis, adenopathy, and urinary 
changes, etc., and, as Audry forcibly puts it, " The bulla of pemphigus 
signifies no more than the rales of pneumonia." 

Some years ago I examined a bulla a quarter of an inch in diameter 
from an ordinary chronic pemphigus, and found that, by examining sec- 
tions made from the edge to the center of the bulla, it could be ascer- 
tained that the bulla was not superficial, but the fluid poured out 
stretched the lower rete cells until they were separated from the corium, 
and, as the process continued, the lower layers were destroyed and the 
upper compressed until, at the center, the roof was formed by the horny 
layer and about the upper two-thirds of the rete, with here and there a 
fragment of a sweat duct or hair follicle depending. At the border, the 
lower stretched cells of the rete were still present. The fibers of the 
corium below the bulla were compressed, and there was free cell-infiltra- 
tion of the upper layers (Fig. 19). Robinson, however, found that in other 
bullae the fluid was between the rete layers, and the horny layer was 
unchanged, while the papillae, corium, and subcutaneous tissue were in- 
filtrated with leukocytes, and the blood-vessels were dilated. And in an 
anomalous pemphigus Pernet found the cleavage at the junction of the 

* " Recherches sur les alterations de la peau, du sang, et des urines 
dans un cas de Pemphigus chronique vrai." Par Audry, Gerard et 
Danlos. Annales de Derm., etc., 4th series, vol. ii. (1901), p. 113. Critical 
references to observations of previous workers. 



PEMPHIGUS. 



3i9 



stratum lucidum and stratum corneum, which agrees with many German 
observations. Audry's most recent observations, as above summarized, 
explain their differences, and confirm what I stated in the second edition 
of this work, viz., that: " No general statement as to the position of the 
bullae can be made in the face of such discrepancies, and probably it 
varies with the age and size of the bulla and in different instances. 
There is no scarring except in rare cases." Eosinophile cells in the 
blood and bullae have been found in excess in chronic ordinary pem- 




Pemphigus bulla. 



a y natural size of bulla; b, whole thickness of epidermis lifted up to form 
the roof of the bulla; c, sweat duct traversing bulla; d, enormous 
round cell-infiltration of the upper layers of the corium; e, coagulated 
albuminous contents of bulla. 



phigus (Audry, Neusser, etc.). Their presence, while admitted by 
Leredde in P. foliaceus and P. vegetans, was denied by him for P. 
chronicus, and he desires to group the first two with dermatitis herpeti. 
formis as blood diseases on the common ground of eosinophilia, and 
differentiating them from P. chronicus from its supposed absence in that 
affection. As it appears, however, to be sometimes present, and as 
Audry has shown that, while present in recent bullae, it may be absent 
in older ones, it is evidently premature to found fundamental distinctions 
on such a disputable factor. In further researches it is important to 
state the exact clinical characters of the bullous eruption and the age of 
the bulla examined. 



320 



DISEASES OF THE SKIN. 



In the main, the contents represent blood serum, and a few leukocytes, 
even when it is clear, and many may be found when it is turbid. Gibier 
found micro-organisms in the fresh bullae of acute pemphigus and in the 
urine; according to him they are beaded organisms, consisting of two to 
twenty individuals joined together in the adult state, and of rounded 
granules isolated or grouped in the young state. Recent observers have 




« 



Safe 



Fig. 20. — Pemphigus vegetans. 

Skin from groin, showing enormously hypertrophied papillae; papillary 
outgrowth; cell infiltration in papillary layer; dilated vessels; sweat 
coil with cell infiltration between the coils. 



found streptococci, and staphylocci are always present. In the chronic 
form the presence of micro-organisms is not so constant. 

In a case of subacute recurrent pemphigus in a child, I found a few 
micrococci in recent bullae, and under cultivation in peptonized gelatin 
minute bacilli developed. Thin, on the other hand, in one case failed to 
find them after repeated search. The chemistry of the contents is un- 
certain; generally feebly alkaline in reaction, it is occasionally slightly 



PEMPHIGUS. 321 

acid — from acetic acid, it is said. Albumin and phosphates are always 
present, but lactate of soda, chlorids, cholesterin, ammonia, and urea, 
uric acid, creatinin, leucin, tyrosin, etc., have been described in different 
instances, but their very variability negatives the idea of their being of 
any etiological importance. Various changes have been found in the 
internal organs, but nothing constantly or even frequently enough, ex- 
cept as regards the nervous system, to make one regard them as other- 
wise than fortuitous. 

Diagnosis. — In chronic pemphigus the bullae appearing in 
crops at short intervals, without apparent cause, antecedent 
symptoms, or lesions, or at most only hyperemia of the skin, 
the process continuing for weeks, months, or years, constitute 
the most distinctive features, and such cases offer no difficulty 
in diagnosis, but P. acutus has to be distinguished from those 
diseases in which bullae occur as an accidental feature, so to 
speak, such as erythema bullosum and urticaria bullosa, or 
where the bullae form instead of vesicles, as in varicella bullosa, 
impetigo contagiosa, eczema, herpes, pompholyx, or where the 
bullae, though pretty constant, form only a part of the eruption, 
as in hydroa, herpes iris, etc. 

In P. acutus there is no antecedent lesion, as in P. chronicus, 
but there may be smart febrile symptoms and severe constitu- 
tional disturbance. In bullous erythema exudativum and urti- 
caria, in hydroa and herpes iris, the other lesions present give the 
clew to the diagnosis. Erythema cxiidatvrum and its ally, herpes 
iris, generally run a definite course of a few weeks; and while 
some febrile symptoms may be present, they are rarely severe. 
The erythema papule or nodule, also, always precedes the for- 
mation of the bulla which forms on it. In herpes iris the central 
bulla with the rings of varying hues is diagnostic. In urticaria 
bullosa, again, the bulla appears on the wheal, and the intense 
itching and tingling would distinguish it from anything but P. 
pruriginosus. In this last, also, wheals appear, but they are 
the secondary lesion, and only develop after the disease has 
existed for some time. Moreover, the bullae are not always 
formed on the wheal, as they are in urticaria bullosa, though 
such is the case sometimes. The diagnosis from dermatitis 
herpetiformis is given under that disease. 

In varicella bullosa, the fact that it was epidemic, the short, 
favorable course, and the co-existence of cases of the usual 
type would be sufficient. 



322 DISEASES OF THE SKIN. 

Prognosis. — The fate of pemphigus patients varies greatly, 
and we possess but few data to enable us to anticipate it. 

The majority of P. chronicus cases get well in the course of 
weeks or months, if judiciously treated, though several recur- 
rences in future years must be expected. A few persist for an 
indefinite period, for years or even for life, and of them a cer- 
tain number may lapse into P. foliaceus. Many of these may 
lead to the death of the patient by exhaustion or by laying him 
open to intercurrent disease. Which of these several courses 
the disease will take we are wholly unable to predicate; the 
longer the eruption lasts the more gloomy is the prospect. If 
the patient is advanced in years, the prognosis must be guarded, 
as he not infrequently does badly, sinking into a typhoid condi- 
tion. The presence of albuminuria is another bad element, and 
when the characters of the bulla are of the destructive order 
(P. crouposus, diphtheriticus, or gangraenosus) the outlook is 
especially bad. Except when the disease is of this kind, the 
pemphigus of infants and children is usually amenable to treat- 
ment. P. pruriginosus is very chronic, and there is no know- 
ing how long it will last. The danger of P. acutus is in propor- 
tion to the extent of skin involved and to the constitutional dis- 
turbance, which may be so great as to destroy life in a week or 
two. 

P. foliaceus is almost invariably fatal, though the cases often 
last for many years. Sherwell * reports the case of a girl, set. 
seven, who recovered from typical attacks in 1877 and 1878, in 
which linseed oil, outside and in, appeared to be of benefit. 
She remained well until 1889, when she had a milder and less 
typical attack, which lasted less than three weeks. The age of 
the patient is as exceptional as the other features, all other 
cases having been adults. A case from Unna's clinique, a man 
set. forty-one, also recovered; he had continuous baths of sul- 
phate of iron and tannic acid — i. e., ink! — to which his recovery 
was ascribed. P. vegetans is almost as lethal, and more rapid 
in its course, but early treatment before the skin is much in- 
volved offers some chance of recovery. 

Treatment. — Until within the last few years in the majority of 
cases of chronic pemphigus the internal administration of arsenic 

* Amer. Jour. Cut. and Gen.-Ur. Bis., vol. vii. (1889), p. 453; Brit. 
Jour. Derm., vol. iii. (1891), p. 357. 



PEMPHIGUS. 



323 



in some form was the most reliable treatment. It should be 
given in small doses at first, such as two or three minims of the 
liq. arsenicalis, increased until it appears to have a hold on the 
disease, or until the limit of tolerance of the patient is reached. 
I am, however, far from giving it the title of " specific " that 
Mr. Hutchinson assigns to it; it approaches most nearly to the 
position he claims for it in the case of children, but fails in many 
older persons, and frequently controls without curing the dis- 
ease. It should never be given where the digestive organs are 
not in a healthy condition, nor where there is any defect of 
health which can be detected and otherwise treated. 

I have found in salicin a most valuable second string, which 
often succeeds when arsenic fails, and as it seldom disagrees 
can be given in cases where arsenic would not be tolerated in 
adequate doses; Like arsenic itself, it sometimes controls but 
fails to cure, but in a large proportion of cases it stops the pro- 
duction of bullae altogether. It must be given in full doses, 
beginning with 15 grains dissolved in water, three times a day. 
The dose may be increased up to 30 grains. Neisser advo- 
cates subcutaneous injections of strychnine. It is worth trying 
when other measures fail. 

In some instances quinine in large doses, iron, cod-liver oil, 
and general hygienic measures, such as a strongly-supporting 
diet, a bracing climate, with rest of body and mind, as far as 
that can be secured, effect a cure when so-called specifics fail. 

Iodid of potassium should never be given; it generally aggra- 
vates bullous eruptions, and I have known them become gan- 
grenous under its influence. 

Locally, dusting powders, such as boric acid with oxid of zinc 
and starch, are often useful; but on the whole in my experience, 
lotions, such as the lactate or glycerin of the subacetate of lead 
(one to six water) or calamin liniment, give most relief from the 
feeling of tension and soreness, but local applications have no 
curative effect. Where the roof of the bullae is prematurely 
removed, boric acid ointment would be the most suitable ap- 
plication. 

In acute pemphigus it is very doubtful whether internal treat- 
ment has any effect, and the rapid course leaves little time for 
remedies to act. In view of the septic character of many cases 
quinine, in from 5 to 10 grain doses in an effervescing potash 



324 DISEASES OF THE SKIN. 

and ammonia mixture, should be given every three or four 
hours. 

If this fails, indications for treatment should be carefully 
'sought after and vigorously followed up, but they are too often 
absent, and all that is left is to combat adverse circumstances as 
they arise, with a general supporting treatment from the 
first, in anticipation of the exhaustion which too often super- 
venes. 

The same local remedies as those recommended for chronic 
pemphigus give temporary relief. 

In P. pruriginosus the itching may be temporarily relieved by 
the antipruritic lotions recommended for chronic urticaria 
(Lotions, F. 20 to 38), such as the liq. carbonis detergens, tere- 
bene, sanitas, nascent sulphur, etc. Internally, arsenic is not 
very successful, but in adults, atropia injections of 1-150 to 
1-60 of a grain might be tried. 

In P. foliaceus internal treatment of all kinds has failed en- 
tirely, either to cure or alleviate. Local means, similar to those 
for eczema, give relief and heal the skin temporarily; the oleate 
of zinc or lead, or boric acid ointments, and the lotions and 
liniments before alluded to, are some among many suitable ap- 
plications. Continuous baths of simple warm water, where 
practicable, give the most relief; in Vienna the patients have 
lived in the baths for months in comparative comfort. 

In P. vegetans Hutchinson has shown that small doses of 
opium, TTLiij to TTLx liq. opii sedativi three times a day, some- 
times controlled the severe and cured the milder form. It was 
not tried till late in the disease in his three fatal cases, but was 
so in my cases, but unfortunately without success. Arsenic 
had some controlling influence in one of his cases for a time, 
but it generally fails egregiously. My patients experienced 
great relief from local disinfecting measures, the foul odor hav- 
ing previously pervaded the whole ward. As nearly the whole 
back becomes excoriated, they should be laid on lint soaked in 
carbolic oil, one in forty, and another sheet of it applied in 
front. The papillary growths in the axillae and groins should 
be freely dusted with iodol, and the mouth frequently rinsed 
with liq. sodse chloratis, and permanganate of potash solution 
sprayed in, several times a day. By these means all fetor is re- 
moved and the patient made much more comfortable. Obvi- 



HYDROA. 325 

ously, such a patient should be placed on a water-bed from the 
first, and the dressings not changed more frequently than is 
absolutely necessary, as every movement gives pain. 

HYDROA. 
Deriv. — vSoop, water, or more directly, i'dpcoa. 

Hydroa was a term used by many of the older dermatologists 
for various bullous and vesicular eruptions, and had fallen into 
disuse until revived by Bazin for certain groups of bullous erup- 
tions which, in their clinical aspects, stand midway between 
erythema multiforme and pemphigus: but some of them are 
separated by a very narrow line from some forms of pem- 
phigus, such as P. pruriginosus. 

Recognizing that there were such eruptions hitherto un- 
classed, many French, English, and American dermatologists 
have taken up the term, while the German school for the most 
part ignore it. 

Hutchinson * used the term for a bullous eruption produced 
by iodid of potassium, but such an eruption scarcely requires a 
separate name; Bazin t proposed three varieties — H. vesicu- 
leux, H. bulleux, and H. vacciniforme. It was subsequently 
acknowledged, even by Bazin himself, that H. vesiculeux is the 
disease that Bateman described as erythema and herpes iris; it 
has therefore no raison d'etre. 

H. bulleux is only one phase of H. herpetiforme, and is now 
disused. Hydroa herpetiformis was introduced by Tilbury 
Fox, and was used in the previous edition of this work and in 
my Atlas for what Duhring subsequently called dermatitis 
herpetiformis: but this latter term is now so generally adopted 
that for the sake of uniformity it is placed at the head of the 
article on the disease. Hydroa vacciniformis seu aestivalis is, 
therefore, the only one left of the group. Hydroa puerorum of 
Unna is a subvariety. 

* Sydenham's Society's Atlas, Plate XXXIII. 

f " Affections Cutanees Arthritiques," pp. 194, 261, and 403. 



326 DISEASES OF THE SKIN. 



DERMATITIS HERPETIFORMIS (Duhring).* 

Synonyms. — Hydroa herpetiformis (Tilbury Fox); Pem- 
phigus pruriginosus (Chausit and Hardy); Herpes gestationis 
(Milton and Bulkley); Herpes circinatus bullosus (E. Wilson); 
Pemphigus circinatus (Vienna School); Dermatites poly- 
morphes douleureuses (Brocq). 

Definition. — A grouped vesicular or bullous eruption asso- 
ciated with ringed and other erythema lesions, and intense 
itching. 

While Bazin, as already shown, to some extent foreshadowed 
it, it is chiefly through Tilbury Fox,f followed by Duhring,J in 
some very able papers on Dermatitis Herpetiformis, that we 
began to get a clear idea of this protean disease. Unfortu- 
nately, the great variations in its clinical aspect led different 
authors in former times to regard these variations as different 
diseases, and to give them different names, according as one or 
other feature struck them most; but now that they are all 
brought into one category it is shown that the disease is not so 
rare as it was formerly considered to be. 

Symptoms. — In cases of acute development it may begin with 

* Author's Atlas, Plates XX., XXI., and Fig. i of xxii, under Fox's title 
of Hydroa Herpetiforme. The plates show several of the variations in 
the clinical characters of the disease. 

Plate II., St. Louis Atlas, shows bullous form well, but in Plate X., in 
concentric circles, the diagnosis is open to dispute. Hutchinson's smaller 
Atlas, Plates XCIX. and C, shows herpetiform character well. 

f Fox, "A Clinical Study on Hydroa," posthumous paper in Amer. 
Archives of Derm., vol. vi. (1880), p. 16. 

% Duhring, "Dermatitis Herpetiformis," Jour. Amer. Med. Assoc, 
August 30, 1884, and several subsequent papers in N. Y. Med. Jour., 1884 
and 1887, and elsewhere, collected by New Syd. Soc. in 1893 in " Selected 
Monographs in Dermatology." Also "Hydroa," Brit. Med. Jour., May 
22, 1886, a general view of the subject by myself. See also " Dermatite 
Herpetiforme," a valuable monograph by Brocq, Ann. de Derm, et de 
Syph., vol. ix. (1888), p. 1, etc., and vol. x., series iii. (1898), pp. 849 and 
945, on " Dermatites Polymorphes Douloureuses," a critical review of the 
views of other authors and of his own. Discussion, Derm. Soc, Lond., 
Brit. Jour. Derm., vol. x. (1898), p. 73. In vol. xi. (1899), p. 213, is an 
abs. of Brocq's criticism on this discussion from vol. ix. of the Annales, 
1898, October and November. 



DERMATITIS HERPETIFORMIS. 327 

shivering and slight febrile symptoms, rarely severe, but often 
the first symptom is only burning or itching, where the erup- 
tion is about to appear. The eruption is bilateral, and in the 
main symmetrical, situated most frequently on and about the 
axillae and groins, the flexor surface of the wrists, or on the 
abdomen or ankles, and is, as a rule, most abundant on the 
flexor surface of the forearms, the front of the trunk, espe- 
cially the abdomen, the buttocks, and outer part of the thighs; 
the legs below the knee are comparatively free, but no part is 
quite exempt. The mucous membranes of the mouth, pharynx, 
and larynx, and conjunctivae may be affected, and the involve- 
ment of the gastro-intestinal canal has been suspected." 1 ' The 
polymorphism, which is one of its most striking clinical char- 
acters, is produced by the varying proportion of its three main 
features; 1. Herpetiform vesiculation; 2. Ringed and other 
erythemata; 3. Burning and itching. 

The eruption, in a typical case, first appears as slightly raised, 
flattish, rose-red papules about a quarter of an inch, which 
speedily enlarge to patches of about half an inch in diameter, 
the center of which soon becomes depressed, and changes to a 
purplish hue; at the same time the patch extends at the periph- 
ery pari passu with the enlargement of the center of involu- 
tion, and so a circle is formed with a raised red margin and a 
flat purplish center. This part of the process closely resembles 
an erythema papulatum, passing into an erythema circinatum, 
but differs from those diseases inasmuch as severe pruritus at- 
tends its evolution; circles, or segments of them, may also be 
formed by the aggregation of papules in this form, or they may 
form groups. When the circle has reached to an inch or more 
across, which it may do in a day or two, the vesicular and bul- 
lous elements usually appear. These vesicles, as a rule, de- 
velop on the spreading border, or on the aggregated papules, 
varying in size from a pin's head to a pea, or larger; but in 
some cases bullae, one inch or more across, are numerous, and 
sometimes the center of the vesicular erythematous circle is 
occupied by a bulla, the whole patch resembling, except in 

*In a fatal case of Galloway's ulceration of the intestines was found 
at the autopsy. For an extensive and primary involvement of the 
mucous membranes, see Morris and Whitfield's case, Brit. Jour. Derm., 
vol. ix. (1897), p. 213. 



328 DISEASES OF THE SKIN. 

coloring, a herpes iris. The erythemata may continue to 
spread beyond the vesicles, and, reaching other lesions, cover a 
large area and form either plaques or even extensive infiltra- 
tions * of a bright red color and thickened, and firm to the 
touch. Vesicles and bullae may also arise singly or in irregular 
herpetiform groups, independently of the erythema, being 
vesicular from their first appearance; moreover, the erythema- 
tous lesions do not all go on to vesiculation. On the develop- 
ment of the bullae or vesicles the itching ceases and a feeling of 
burning or tension takes its place. Sometimes burning is the 
first, or it may be the chief subjective symptom, and is only re- 
lieved when the contents of the bleb are evacuated; but, like 
herpes vesicles, they do not rupture spontaneously, but dry up 
and leave a thick scale. The contents are usually quite clear, 
but sometimes become purulent and more rarely bloodstained. 
In one case micrococci were readily grown by me from the 
clear fluid of a bulla, introduced into gelatin peptone. 

Although there are exacerbations at intervals, there are 
sometimes no complete remissions, fresh erythematous and 
vesicular lesions developing almost daily. Erythema, vesicles, 
bullae, and pustules may be simultaneously present in different 
parts of the body. 

The course of the disease is long and uncertain, often lasting 
months, or even years (twenty, Brocq; I have known over ten), 
unless controlled by treatment, and relapses or recurrences are 
the rule. In very chronic cases, therefore, the constant scratch- 
ing may entail the usual consequences, including superficial 
ulcers, scabbing, boils, lymphangitis, enlarged glands, and 
lichenification (Hallopeau), though as a rule " the scratched 
skin " is but little developed, considering how bitterly the pa- 
tients complain of the itching. As a rule, the general health is 
unaffected for a long time. Though the loss of rest may wear 
out the patient greatly, fatal cases are rare except in the aged, 
and then delirium generally occurs towards the end. As in 
pemphigus, so in this, scratching or blows will sometimes pro- 
duce bullae. Brocq and Tenneson have recorded purpura 
patches as a complication. 

* In two fatal cases in octogenarians this condition preceded for 
several days the vesiculo-bullous manifestations. J. 619 and K. 752, 
Private notes. 



DERMATITIS HERPETIFORMIS. 



329 



The urine has been frequently examined, but though the 
changes are numerous they are too inconstant to have much 
clinical value. Oliguria is said to be the rule (Besnier), but 
polyuria is sometimes present, and Leredde says it is of favor- 
able omen. There have also been found albuminuria, glyco- 
suria, indicanuria (Leredde), diminution of urea and uric acid, 
and of toxicity of the urine. Hardouin * records a case in 
which the attacks always occurred after periods of hypoazo- 
turia and coincided with a return in great part of the elimina- 
tion of urea. Bar in herpes gestationis agrees with the first, 
but not the second proposition. Tenneson thinks that marked 
hypoazoturia is a special feature of the disease, but Besnier has 
shown that it is a common feature in all forms of extensive der- 
matitis. On the other hand, Hallopeau and Tete have found 
an alkaloid in the urine which provoked an eruption on the skin 
of a guinea-pig. Perrin says that in herpes gestationis there is 
diminution of toxicity in the urine, and when a cure is effected 
the toxicity rises again. 

Variations. — Where all is variety it is difficult to say what is 
a typical case and what a variation; nevertheless, while the pre- 
ceding is a fair account of a severe case, there are great dif- 
ferences in appearances, according to the predominance of the 
erythematous, vesicular, bullous, or pustular elements, and the 
severity of the itching. Polymorphism is absent in some at- 
tacks, or may be inconspicuous. 

Sometimes the erythematous element is the only one present, 
or is so predominant \ that the vesicular part may be over- 
looked. In Frank W., aet. four, flat hemp-seed to pea-sized 
erythematous papules appeared on the abdomen and thighs, 
and circinate and gyrate patches, from half to one inch in 
diameter, developed from these; one gyrate patch extended 
from the pubes to the umbilicus, slightly scabbed from scratch- 
ing. This erythema continued several weeks, with the acces- 
sion of fresh papules from time to time, but no vesicles, and 
then an outbreak of vesicles, grouped and scattered, appeared 
on the lower limbs, with a ringed erythema interspersed. At- 
tacks of this kind, and also of the circinate erythema, continued 

* A tin ales de Derm., etc., vol. i. (1900), p. 1137, gives numerous refer- 
ences to previous work on the subject. 

f Master S., set. twelve, private notes, F. 79, was an example. 



330 DISEASES OF THE SKIN. 

at intervals for between two and three years, but there was sel- 
dom erythema alone after the first; occasionally there were pus- 
tular * instead of vesicular elements. Again, in a woman, aet. 
forty-four, the typical rings and segments of circles of papular 
erythema, attended with moderate itching, came out in crops, 
but there was no vesiculation at all throughout its course of 
three or four months. 

In Henry N., aet. twenty-nine, the disease had existed only 
a month; beginning on the flexor surface of the forearm, the 
eruption extended unequally over the whole body, except the 
scalp, and consisted entirely of itching, erythematous papules, 
patches, and circinate forms; vesicles one-eighth of an inch 
across existed on the palms only; he speedily recovered under 
treatment. 

On the other hand, the bullous element may be the prominent 
feature. Thus in a youth of eighteen under my colleague, Sir 
Thomas Barlow, bullae an inch or more in diameter were 
present, more or less all over, beginning as small vesicles and 
rapidly enlarging to various sizes; from time to time crops of 
erythematous lesions of the usual type came out symmetrically, 
and on these vesicles might or might not appear, and rings of 
vesicles with central bullae sometimes were seen; a few of the 
vesicles became purulent. In other cases the vesicles remained 
very small. This man was under my observation for years, 
with annual recurrences, sometimes slight, sometimes severe, 
and with every variation in size of the vesicles or pustules, and 
in the proportion of erythema. 

In Samuel P., aet. forty-five, bullae, without preceding 
erythema, developed on the ankles and dorsum of the feet only, 
while on the trunk and wrists there was an exclusive develop- 
ment of the usual erythema forms; he got well under treat- 
ment in about six months. 

The size of the vesicular element varies within wide limits; 
a millet seed to a pea is the usual size, but they may be from 
a pin's head upwards. In a case reported by Morris and Whit- 
field the lesions resembled those of vaccinia. 

Some cases look like a universal herpes zoster, f for which 
they are sometimes mistaken; others approach to the ordinary 

* Plate XXII., Fig. i, of my Atlas represents one such attack, 
f Plate XX. of my Atlas is a well-marked example. 



DERMATITIS HERPETIFORMIS. 



33 1 



pemphigus type, and if the bullae are in circles they are reported 
as pemphigus circinatus; others, again, as persistent erythema 
circinatum. 

In one case bullae of the ordinary pemphigus type developed 
on the feet and small bullae came out subsequently ; on the other 
hand, G. H. Fox of New York published a case which began as 
a herpetiform eruption, and lapsed into a pemphigus. 

When the pustular element is much developed cases may re- 
semble and are sometimes reported as examples of the impetigo 
herpetiformis of Hebra. A severe case of this kind has been 
reported by Fordyce * in a male, who recovered. Wende's f 
was severe, but of a different type. There were rings of pus- 
tules with erythematous rings around it. 

When the itching is very severe the appearance of the dis- 
ease is much modified by the consequent scratching, and the 
characters of the disease may be more or less concealed. In 
Charles B., a stoker aet. fifty-four, the scabbing and excoria- 
tions were so great that at first sight pediculosis was suggested, 
but the distribution not agreeing with that, close examination 
showed circinate and herpetiform groups of pin's-head papules, 
with a pin's-point vesicular cap. The patient was much dis- 
tressed and worn. As the treatment relieved the itching, the 
true character of the eruption became more evident. In many 
cases the itching is moderate and only pronounced at night. I 
have also seen a case in which, with all the other symptoms 
present, itching was absent; this is very exceptional. 

Circumscribed cases occur in which the eruption is confined to 
one or more regions. In the case of a man under me at 
U. C. H. for years, the eruption was limited to the axillae and 
its folds, and sometimes about the gluteal cleft and groins 
there were grouped pea-sized vesicles with great irritation. 
Audry mentions one case of a girl of sixteen, who from the age 
of three was subject to the eruption on the back of the wrists, 
hands, and bend of the elbows and knees. In another, a 
woman, aet. twenty-five, it was in the same positions on the 
upper extremity, but none on the lower. Corlett's case was 

* Fordyce's case, Amer. Jour. Cut. and Gen.-Ur. Dis., vol. xv. (1897), 
p. 495, with colored and microscopical plates, 

fWende, loc. czt. vol. xix. (1901), p. 171. Compare with Hallopeau 
and Liddell's cases {vide pp. 333-334). 



332 DISEASES OF THE SKIN. 

limited to the forearms and thighs, Balzer's to the scalp, back, 
and leg. Gaucher and Barbe, etc., also record localized cases. 
Brocq's case left cicatrices and epidermic cysts on the site of 
the bullae. 

Herpes gestationis was the name formerly given to der- 
matitis herpetiformis when it occurred in pregnant or puerperal 
women, before its nosological position was understood. 

Brocq in his earlier writings divided the diseases into dif- 
ferent groups of acute and chronic pruriginous polymorphous 
dermatitis, and placed herpes gestationis in a third group; but 
there are intermediate links of every kind, and I have seen 
exactly the same lesions in a pregnant woman, an elderly 
spinster, and in a man; the pregnancy is, therefore, only one 
element in the etiology, and Brocq admits it is only a variety. 
Out of fifty consecutive cases of D. herpetiformis of mine six 
were of this type. 

Once it has appeared it recurs usually with each succeeding 
pregnancy, being sometimes the earliest indication to the pa- 
tient of her condition. It then continues usually throughout 
child-bearing, a violent outbreak ensues a few days after de- 
livery, and then it gets well, either at once or gradually, by the 
attacks becoming of diminished severity until they reach the 
vanishing point. Such was the case of Emma H., aet. thirty- 
four, in whom it recurred in three successive pregnancies. 
There are, however, considerable variations in its behavior. It 
may begin at any period of pregnancy, or soon after it. 

In Elizabeth G. it occurred in four successive pregnancies 
under my observation. The first three days after confinement 
with her fourth child; the second at the sixth month of preg- 
nancy; the third in the eighth month, and the fourth in the 
seventh month. All the symptoms were present in a marked 
degree. Barendt's case was more constant; four out of five 
attacks were in the fifth month of pregnancy, it stopped one 
month before, and recurred soon after confinement, lasting 
from one to eight weeks. 

Dinah S. in eleven years had seven pregnancies, and had at- 
tacks in each one. She and E. G. scratched the bullae into 
ulcers on the leg. Latterly S. had never been free from eruption. 
In Mary W. it missed one pregnancy, but recurred the next. 



DERMATITIS HERPETIFORMIS. 333 

In Jane F. at the fourth attack, she was found not to be preg- 
nant, but to have cancer of the cervix uteri. She had not been 
free for three years, and it persisted badly for nine months after 
her last confinement. It is said that the death of the fetus fre- 
quently occurs in herpes gestationis, but I cannot support this 
from personal experience. 

Duhring, Besnier, and Galloway * also report cases which 
have persisted after childbirth or recurred independently of it, 
and even where it has disappeared during pregnancy and re- 
curred when the menses were established. Bulloch obtained a 
pure culture of staphylococcus albus from the fluid of a recent 
bulla, in a third attack just after parturition. 

Hydroa Bulleux, of Bazin or, as Fox preferred to call it, 
Hydroa Pruriginosa, is a very rare form, and is attended at 
its development with intense itching, and sometimes preceded 
by slight febrile symptoms, followed by the formation of small 
bullae not exceeding the size of a split pea, and commencing as 
vesicles, without any antecedent lesion. They increase in size, 
with the contents clear at first, but becoming turbid in a few 
hours. As the contents get absorbed, slight umbilication is 
produced, and ultimately the bulla dries up, leaving a thin, 
leafy scale, or, if scratched, a blood crust; or where many bullae 
have coalesced, foliaceous crusts, something like P. foliaceus, 
and when these are thrown off a hyperemic, subsequently pig- 
mented, surface is left. The eruption comes out in a succes- 
sion of almost continuous crops, the bullae being discrete or 
grouped irregularly, but never in circles. It may be partial or 
general, affecting even the palms and soles, but more abundant 
in some parts than others, and with free intervals. But the 
disease does not always begin with bullae of the preceding char- 
acters; thus Fox's case \ began with a circinate erythematous 

* In Galloway's case the first three attacks began three days after con- 
finement, the fourth in the fourth month of pregnancy, and continued 
for three months after parturition; there was eleven per cent, of eosino- 
philia — Brit. Jour. Derm., vol. xiii (1901), p. 413. 

f Case 7 of Tilbury Fox's paper, loc. cit. , which was also under my ob- 
servation throughout its whole course. A subsequent attack is recorded 
by Sangster and Bruce on " Rare Form of Itching Vesicular Eruption, 
(?) Hydroa Bulleux," Med. Times and Gas., January 5, 1884, with dis- 



334 



DISEASES OF THE SKIN. 



eruption, like that already described, which thus forms a link 
with the usual type of dermatitis herpetiformis. 

Hallopeau * has described in a man, aet. sixty-three, an 
anomalous form arranged in concentric circles of closely 
crowded vesicles, or, as he calls it, " en cocardes." There were 
erythematous circles between the vesicular circles which varied 
from two to six. It resembled one of the forms of Bateman's 
herpes iris, but instead of being on the extremities, especially 
the hands, it was almost entirely on the trunk, and was accom- 
panied by intense itching. The concentric arrangement ceased 
after a time, and then ordinary blebs appeared. Death ensued 
eight weeks from the onset with acute nephritis. There was a 
purpuric eruption towards the end. Liddell of Harrogate and 
Wende have recorded somewhat similar cases, and Erasmus 
Wilson also in 1874, as " Pemphigus iris." 'The diagnosis is 
open to discussion, and I should be more inclined to regard 
them as an unusual form of herpes iris than of dermatitis 
herpetiformis. 

Complications. — Besides those due to scratching, keratosis 
palmae et plantae, as already described in Pemphigus, have been 
observed by Besnier, Brocq, and myself. 

Purpuric patches have been observed by Brocq and Tenne- 
son. 

Vegetations following the bullae resembling those of pem- 
phigus vegetans have been recorded by Hallopeau, Brocq, 
Wende, and myself. They are probably a product of pus cocci. 

In Hallopeau and Brodier's case the nails fell off, and the 
vegetations disappeared spontaneously in a few weeks, leaving 
brown stains. Scars, pigmented or not, are only left when 
there has been severe scratching or suppuration, as in Hallo- 
peau's case.f Hallopeau has observed pemphigus foliaceus 

tinctly herpetiform features. Plate LXXII. of T. Fox's Atlas repre- 
sents one phase of the eruption. 

*St. Louis Atlas, Plate X. Also good critical note by Pringle in Eng- 
lish edition. Liddell, Brit. Jour. Der?n., vol. viii., October, 1896^.385. 
Erasmus Wilson, " Lectures on Dermatology " (third edition, 1874), p. 
124; and Coll. Surg. Museum, No. 12 of 1895 Catalogue, where I have 
classed it with Erythema iris. In 1875, Catalogue No. 130, Wilson called 
it Pemphigus iris. 

f A case with lichenification, cicatrices, and persistent mental disturb- 
ance. Annates de Derm., vol. iv. (1893), p. 774. 



DERMATITIS HERPETIFORMIS. 



335 



supervene in long-standing cases, but Brocq disputes this diag- 
nosis and calls the sequel " Herpetide maligne exfoliatrice " 
after Bazin. 

Brocq * wishes to widen the conception of D. herpetiformis 
into one vast group called by him dermatites polymorphes dou- 
loureuses, characterized by: 

1. Painful phenomena of variable intensity, but nearly al- 
ways strongly marked, often out of proportion to the erup- 
tion. 

2. Polymorphic eruptions more or less erythemato-vesicular, 
erythemato-bullous, sometimes urticarial, papular, sometimes 
herpetiform, more often grouped, but possibly disseminate. 

3. A marked tendency to successive crops of eruption. 

4. Preservation of general good health with few exceptions. 
He divides them in four groups: 

I. Acute polymorphic painful cases. 

II. Chronic polymorphic recurring painful cases. 

III. Herpes gestationis cases, or painful polymorphic gesta- 
tion cases. 

IV. Intermediate or transition cases between the above and 
other related morbid types. 

Each of the above groups has minute subdivisions, and for 
these and the grounds upon which he founds them the mono- 
graph itself must be referred to. Much can be learned from it, 
but I regret that it has not convinced me of the practical ad- 
vantages of adopting his views and nomenclature as distin- 
guished from those founded on those of the majority of modern 
dermatologists. 

Etiology. — Our knowledge is insufficient to allow of many 
positive general statements being made. Bazin lays stress on 
the presence of a gouty predisposition: but my experience does 
not lend much support to this. Exposure to cold has seemed 
an exciting cause sometimes; nerve shock and severe mental 
emotion have immediately preceded the attack in many instances 
(G. T. Elliot collected ten cases), and nervous exhaustion from 
worry, anxiety, loss of rest, etc., is probably a predisposing in- 
fluence. 

Its occurrence during pregnancy, and recurrence with several 
succeeding pregnancies, show that there is some etiological re- 
* Loc. cz't., Annates, vol. ix. (1898), p. 953. 



33 6 DISEASES OF THE SKIN. 

lationship, probably reflex irritation of the vaso-motor centers; 
and the irritation of these centers, either direct or indirect, is 
the most probable pathology, so that this brings it close to 
pemphigus vulgaris, the difference being more clinical than 
pathological. 

Age. — Dermatitis herpetiformis occurs in both sexes, being 
most frequent in men in spite of the gestation cases of women, 
and least often in children. A child, set. three, is the youngest 
I have met with. The oldest case I know of was one of my 
own, a man, aet. eighty-six. It is, however, most common in 
adults, between thirty and forty, but it is fairly frequent be- 
tween twenty and thirty, and between forty and fifty. 

Bowen has recorded five cases in children apparently due to 
vaccination, but the diagnosis was not undisputed (vide Vac- 
cinides). 

Pathology. — This can only be conjectured; my own view is 
that it is the same as that of pemphigus, the difference between 
the two affections being clinical rather than pathological, and 
probably dependent on the individual rather than on the toxin. 
Hallopeau shares this view, while those of the Vienna School 
who follow Kaposi have always refused it even a clinical sepa- 
ration from pemphigus. On the other hand, Besnier, Brocq, 
and most of the French School support Duhring in considering 
it quite distinct. Many French observers, especially Perrin and 
Leredde, consider that the toxin is a product which in health 
is eliminated by the urine, but in renal disease accumulates and 
acts on the nervous system, the skin, and the blood cells — 
hence eosinophilia. They cite its frequency in pregnant women 
as corroborative, as the interference with the renal function is 
so frequent in pregnancy; but that can equally well be cited as 
a proof of its being due to reflex nerve irritation or to a toxin 
from a non-renal source, such as the intestine. In favor of the 
latter I have seen several cases, and in two senile cases the 
probability of the intestine being the source of the toxin was 
very strong. 

Leredde lays great stress on the abundance and constancy of 
eosinophile cells in the blood, in the vesicles and bullae, the 
dermis and the epidermis, in this disease, and considers this a 
diagnostic feature, as in no other diseases except pemphigus 
vegetans and foliaceus are they found constantly in such abun- 



DERMATITIS HERPETIFORMIS. 



337 



dance. Hence he considers them all hematodermites.* In 
leprosy they may be as abundant in some cases and not above 
normal in others. 

Normally there are one or two eosinophile cells in a hundred 
white corpuscles, while . in D. herpetiformis there are always 
eight to fifteen, and may be as many as forty per cent., but 
cases as low as four per cent, are recorded by several observers. 
The number present rises or falls with the exacerbations and 
remissions of the disease. There are some other less impor- 
tant changes also noted by Leredde in the blood. At the same 
time much more research is required before his deductions can 
be accepted unreservedly ;f and, as already mentioned in the 
pathology of pemphigus, other observers dispute his claim that 
the abundance is diagnostic or even constant. 

Anatomy.— Unna| has examined the lesions of a mild and a severe 
form, and although they appear to be very different at first sight, he says 
the histological basis is the same, viz.: " The edema and cellular infiltra- 
tion corresponding to a vascular area of the skin, whose chief seat is the 
papillary bod}'; the utterly passive behavior of the epithelium, which 
only presents edema and inter-epithelial blisters, or is completely 
elevated by serum; and finally, the complete absence of leukocytes." 

Diagnosis. — The most distinctive features are the occurrence 
of severely itching, circinate, and papular erythematous lesions, 
with vesicles and bullae, which have a tendency to group her- 
petiformly. 

It is most likely to be mistaken for pemphigus, especially 
pemphigus pruriginosus, and bullous forms of urticaria and 
erythema exudativum. The extreme itching is sufficient to 

* " Hematodermites," La Presse Medic ale, December 28, 1898. 

\ Examination for eosinophiles in the vesicles. — 1. The liquid maybe 
examined directly under a cover-glass, when the eosinophiles may be easily 
recognized by the presence of large reflecting granules. 2. After fixing 
by alcohol-ether, stain by concentrated hematein of Meyer. Then 
immerse for a second in a one per cent, watery solution of Orange G. 

Examination of the blood '.—The blood should be evenly and thinly 
spread on a cover glass fixed by alcohol-ether, stained by strong hema- 
tein and then by the following solution : Alcoholic solution of eosine 1, 
water 70, spirit of 90 strength, 30. (From Hallopeau and Leredde's 
" Dermatologie," p. 719. 

X " Histopathology," p. 144. 



338 DISEASES OF THE SKIN. 

distinguish it from the ordinary forms of pemphigus, and in the 
case of H. bulleux the bullae are of small size. 

From pemphigus pruriginosus there may be some difficulty, 
but the mistake would not be of great practical importance. 
As a rule the bullae are smaller in hydroa, but this is not re- 
liable. In pemphigus pruriginosus there are no erythematous 
lesions at first, and when wheals subsequently form they are 
not symmetrical; the vesicles and bullae tend to group in 
hydroa, not in pemphigus pruriginosus. The monomorphous 
character of the latter is the most reliable feature. If Leredde 
is correct, the presence of a high degree of eosinophilia would 
be decisively in favor of dermatitis herpetiformis. 

In urticaria bullosa there would not be the symmetry in the 
lesions which is observable in the erythema of dermatitis her- 
petiformis nor yet the tendency to group and take circinate 
forms, but there would be itching pink lesions from which the 
bullae would arise, but none independently of them, except 
sometimes on the palms and soles. 

In erythema bullosum there is not severe itching, and there 
would be no bullae or vesicles arising independently of the 
erythema. 

The erythematous cases, in which there are no vesicles for 
a long time, would naturally be mistaken for erythema exuda- 
tivum circinatum. The persistently recurring exacerbations, 
and the far greater itching than that of ordinary erythema, 
should excite suspicion until time and vesicles come to our 
assistance. 

Hallopeau's form (en cocardes) must be very difficult to dis- 
tinguish from herpes iris, in which such an arrangement is the 
rule. The eosinophilia test might be applied. 

Prognosis. — Most cases, if judiciously treated, will get well in 
a few weeks to a few months, but the disease tends to recur 
in future years, the attacks becoming weaker and eventually 
ceasing, which is very much the course of ordinary pemphigus. 
On the other hand, some cases go on for many years, the pa- 
tient never being quite free, or having only short intervals of 
freedom. Severe cases in the aged are apt to terminate fatally; 
while the mortality at all ages is only about five per cent. 

Treatment. — Place the patient in as favorable a position as 
his circumstances will admit of, so as to avoid overwork, 



DERMATITIS HERPETIFORMIS. 339 

whether of body or mind, or exposure to worrying conditions. 
The state of the digestive organs must be inquired into, and if 
necessary treated; a highly nutritious and easily digestible diet 
ordered, alcohol restricted, and sometimes avoided altogether; 
change to a fresh bracing air, if possible, should be arranged, 
and tonics given suited to the patient. While these general 
measures should be carried out as far as practicable, they really 
only pave the way for specific medicines, such as arsenic, salicin, 
and phenacetin, and in some cases quinine and belladonna. 
Arsenic, in this as in most recurrent bullous eruptions, has long 
had the leading role, but it is powerless as a rule until 8 or 10 
minim doses of the liquor arsenicalis, or, in some cases, the 
limit of the patient's tolerance of the drug has been reached. 
Then in favorable cases the bullae cease to develop in such num- 
bers, or there are longer intervals, and ultimately the eruption 
ceases altogether. This is usually attained in a month or six 
weeks, but it may require a longer course. Cacodylate of soda 
would probably act in a similar manner, but the risks attending 
its use are pointed out in the article on Psoriasis. Of late 
years arsenic has, in my practice, been largely superseded by 
salicin. It is given in the same kind of case, and has so often 
succeeded, even where arsenic has failed, that I now generally 
start with it. Beginning with 15 grains of salicin three times 
a day, the dose may be increased rapidly up to 25 or 30 grains, 
and if the bowels are kept open there is rarely headache or 
other disagreeable symptoms. It is soluble to the extent of 19 
grains to the ounce. As in pemphigus, both these drugs in 
some cases control the eruption without altogether preventing 
it, and in others fail completely. 

Tilbury Fox preferred quinine in large doses, 2 to 10 grains; 
and I, also, have found it efficacious in some cases, given with 
an effervescing citrate of potash mixture. Cod-liver oil is 
generally desirable. 

Phenacetin is sometimes very successful, especially in cases 
where the burning and itching are very intense and tend to 
wear out the patient. It may be given in 5- to 10-grain doses 
three times a day, or as a supplement to arsenic or salicin 10 
grains at night, when it helps to secure rest. Morris strongly 
advocates this drug. Antipyrin acts in a similar way. 

When the other drugs have failed belladonna has sometimes 



34 o DISEASES OF THE SKIN. 

succeeded; it, also, must be given in full doses, beginning with 
15 minims and increasing up to 30 minims, or more, of the 
tincture three times a day. Should there be distinct evidence 
of the gouty diathesis, alkalies, colchicum, and diuretics, espe- 
cially acetate of potash, would be appropriate, but iodid of 
potassium must never be given, as it is liable to produce serious 
aggravation of the eruption. 

Locally. — Duhring found that sulphur ointment gave great 
relief in some cases. Where practicable, sulphici of potassium 
baths, from gss to Jij to the 30-gallon bath, might be tried, and 
Harrogate, Strathpefrer, or Aix-la-Chapelle would be indicated 
among the spas. 

Another form of using sulphur baths is that of nascent sul- 
phur, by means of the sulphaqua powder dissolved in the water, 
or by dissolving 5J to §ij of hyposulphite of soda in one jug, and 
5ss to 5j of tartaric acid in another, mixing them together and 
then adding them to the bath. Where the bullae are large and 
have ruptured and the eruption is extensive, these sulphur 
remedies might be too powerful to use; then alkaline and bran 
baths, with or without liq. carbonis detergens, frequently give 
great relief, and if taken at bedtime will promote sleep, which 
is usually otherwise much disturbed. Dusting powders of 
starch and zinc, and sometimes of kaolin and a small quantity 
of creasote, are useful. In other cases lotions are preferable; 
those of calamin and lactate of lead are good, but generally 
the liquor carbonis detergens 5ij to gviij, or other anti-pruritic 
agents (Lotions, F. 20 to 38), are the most reliable, and by ob- 
viating the necessity of scratching, materially facilitate the re- 
turn to health. Boric acid ointment would probably be the best 
application to raw surfaces. It must be remembered that some 
cases improve w T hen they are kept in bed at one temperature. 



HYDRO A VACCINIFORME SEU AESTIVALIS. 341 



HYDROA VACCINIFORME SEU AESTIVALIS.* 

Synonym. — Recurrent summer eruption (Hutchinson); Hy- 
droa puerorum (Unna). 

Definition. — A recurring summer eruption of childhood, 
usually with vesicles, which leave scars. 

Bazin was the first to describe this disease in 1862; but owing 
to its variety and rarity, and his description applying to one 
phase of it, it has only recently been identified. Hutchinson 
made his description independently, in 1888. Since then cases 
have been reported by numerous observers in Europe and 
America, both North and South (Bahia), so that it is practically 
ubiquitous, though still a rare disease, as less than thirty cases 
have been published. 

Bazin's description, from a single case, though he subse- 
quently saw others, is as follows: " It appears after exposure to 
much wind or to the sun. There may be slight malaise or 
anorexia, and then the eruption comes out on the uncovered 
regions, such as the nose, cheeks, wrists, hands, and then other 
parts, including sometimes the mucosa of the mouth. Red 
spots first appear, on which rounded vesicles, like those 01 
herpes, spring up. On the second day distinct umbilication is 
produced; then the contents become opaque, and resemble a 
smallpox or a vaccine pustule; each dries up into a crust from 
the center toward the circumference, and when the crust falls 
off leaves a depressed cicatrix; these scars, when numerous, 

* Illustrated. Author's Atlas, Plate XXII., Figs. 2 and 3. Hutchin 
son's smaller Atlas, Plates CVIII. and CX. Extreme cases, both females. 

Literature. — Bazin, loc. cit. Hutchinson, Clin. Soc. Trans., vol. xxii. 
(1889), p. 80, with chromolithograph. Jamieson, " Diseases of the Skin," 
3d ed., p. 172 — these cases were originally reported as xerodermia pig- 
mentosa, Lancet, vol. ii. (1888), p. 33. Unna. Monatshefte fiir ftrakf. 
Derm., August, 1889, p. 108. Handford, Illustrated Med. News, vol. 
1889, with good colored illustration of phase Bazin described. Brit. Jour. 
Derm., vol. iv. (1892), p. 128, — a good abstract of Buri's case, with com- 
ments by Brooke. C. Boeck, Archiv f. Derm., vol. xxvi. (1894), p. 23 
(four cases). J. T. Bowen, Jour. Cut. and Gen.- Ur. Dis., vol. xii. (1S94), 
p. 89, with histolog}^. L. Brocq, Annates de Derm., 3d. ser. vol. v. 
(1894), p. 1 133. Mibelli has also published a case with histology, Monatsk. 
fiir Derm., vol. xxiv. (1897^ p. 87. 



342 DISEASES OF THE SKIN. 

give the aspect of antecedent smallpox. When the sero-pus is 
abundant the crusts are thick and yellow, like impetigo. Suc- 
cessive crops prolong the eruption for months, and recurrences 
from change of temperature are frequent. Arthritic symp- 
toms often precede the eruption." 

General Description. — The disease generally begins in the first, 
second, or third year of life, though it may be later. The erup- 
tion develops chiefly on the uncovered parts, and is generally 
preceded by burning or pain, fullness, but not itching, of the 
region attacked, and by some general discomfort, anorexia, 
sleeplessness, etc. Then the red spots appear, and on these, 
rounded vesicles develop singly or in groups like herpes. 
These vary in size from a millet seed to a large pea if discrete, 
or they may coalesce into an irregularly outlined, flattish bulla; 
the redness remains as an areola. These lesions may follow 
three courses: the vesicles may dry up in a day or two, leaving 
a thin scab; or they may rupture and leave a yellowish crust; or 
the larger vesicles sink down, and dry in the center into a thin 
red scab, surrounded by a ring of fluid, and may enlarge slightly 
in this form, and closely resemble a vaccination vesicle, having 
even dissepiments, so that a single prick does not empty it. It 
is to this phase that Bazin's name applies. In either case, after 
the scab has separated a reddened, slightly depressed scar is 
left, which eventually gets white, but is indelible, so that the 
patient looks as if he had had smallpox. Occasionally the 
lesion is arrested at the erythematous stage, and then scarring 
may be avoided, but it is generally a very marked feature. The 
individual lesions develop and decline in three or four days, but 
the time of the falling off of the scab is variable according to 
its depth. The whole attack lasts from two to three weeks, as 
all the groups do not develop simultaneously, and all phases 
may sometimes be seen together. Itching is never a prominent 
feature. The favorite regions are the face, especially the cheeks 
and nose; the ears, which are so severely involved as to be 
often reduced to mere cicatrized gristle; the neck, especially at 
the sides; the back of the hands; and less frequently the exten- 
sor aspect of the arms and forearms, and even the legs. Other 
regions are occasionally involved, and it has been pretty gen- 
eral, but with only a sparse distribution of the diseased foci. 
The patient is liable to recurrence, from spring to autumn in- 



HYDROA VACCINIFORME SEU AESTIVALIS. 



343 



clusively, few attacks occurring after October and before Febru- 
ary. The worst are in the hot months, the sun being a power- 
ful developing factor, and the wind almost as irritating, the 
eruption often breaking out a few hours after exposure. The 
attacks get milder at puberty, and generally cease by the time 
the patient is grown up. 

Variations. — While the above is the type there are many de- 
partures from it. In a lady of twenty-two sent to me by Dr. 
Blake of West Wickham, the disease began in April, at the age 
of thirteen, and subsequent attacks in the summer and spring. 
In four of the attacks the lesions suppurated, and foveated 
scars were abundant all over the face except round the mouth 
and chin. The nose and ears were much disfigured by the scar- 
ring, the hands were red, swollen, and scabbed, as if from 
broken chilblains, which they resembled closely in the winter. 
The knees and elbows were involved during a winter at St. 
Moritz. The eruption was worse at the periods. White of 
Boston * reports two winter cases, but they were not quite 
typical. Eosinophilia eight to fifteen per cent, was present. 
Colcott Fox's f case of vesicular recurring winter eruption is 
analogous. McCall Anderson % had two male cases with a 
pigment allied to uro-hemato-porphyrin in the urine. In an- 
other case of Fox's, a girl of nine, in whom the eruption had 
recurred every spring and summer from birth, clear vesicles 
which left scars like those of variola were localized to the face, 
ears, upper part of the neck, and when at its worst the hands 
also. 

Etiology. — The earlier cases were all boys, but fuller experi- 
ence has shown that sex has no influence. Most have com- 
menced in early childhood, generally under three years, but 
there are a good many exceptions, and it appears that several 
of the female cases have had a late commencement. Boeck's 
case began at twenty-six, Van Dort's at eighteen, and both 
Jamieson's case and one of mine began at thirteen. 

Nearly all have their attacks worst and most exclusively in 
the summer, but a few, like my case, have been worse in the 
cold weather; not only sun, but artificial heat and cold winds 

* Amer. Jour. Cut. and Urin. Dis., vol. xvi., 1898, November. 
\ Brit, /our. Derm., vol. x. (1898), p. 410. 
\Ibid.,?. 1. 



344 DISEASES OF THE SKIN. 

are efficient excitants, and in one of Unna's cases, cold and sea- 
baths would produce an attack. Three brothers of one of 
Unna's cases were said to have suffered in the same way, but it 
must be admitted that Unna's cases differ somewhat from the 
others in several respects, one important difference being that 
the vesicles and bullae were quite superficial and left no scar, 
and often the lesions stopped short at an early stage, or re- 
mained as papules. 

Pathology. — This is unknown; it is presumably a vaso-motor 
neurosis, and a congenital susceptibility to external irritation 
may be assumed, but this does not take us very far. That it is 
not merely the chemical action of the sun's rays analogous to 
Rontgen-ray burns is shown by the fact that other agents will 
produce it. 

Diagnosis. — The most striking features are the onset in early 
life, and the annual recurrences in the warm season of the year, 
especially after exposure to the sun and wind. The lesions 
occur symmetrically on the exposed parts, are vesicular in type, 
single or herpetiform in distribution, with a tendency in the 
large ones to dry from the center towards the periphery, and 
for all to leave indelible scars. There are only a few scar-leav- 
ing eruptions which could give rise to error, viz., strumous dis- 
ease of the skin, lupus vulgaris, lupus erythematosus, and 
syphilis. The symmetry of the scarring would at once show 
that it was not strumous or lupus vulgaris, and while this would 
not be true of lupus erythematosus, in which, too, the ears are 
often involved, that disease rarely occurs in childhood, is gen- 
erally worse in the winter, never has perfectly free intervals, 
and of course never develops with vesicles after exposure to' the 
sun or wind. Hutchinson and Jamieson see a resemblance to 
xerodermia pigmentosa. The points of resemblance are the 
onset before three years old, the malign influence of the sun, 
and the distribution on uncovered parts; the last point of re- 
semblance is more apparent than real, as the distribution of 
xerodermia pigmentosa is very exact, accords with that of 
many other diseases, and extends beyond the area of exposure 
and corresponds with a vascular area governed by certain vaso- 
motor centers, while in hydroa vacciniformis the area of disease 
rarely extends beyond the parts exposed; other differences 
are: 



HYDROA VACCINIFORME SEU 7ESTIVALIS. 345 

Hydro a Vacciniforme. Xerodermia Pigmentosa. 

Course intermittent. Slowly progressive. 

Tends to improvement and No tendency to improvement, 
spontaneous cure. but to malignant growths 

and death. 
Lesions are vesicular and Lesions are pigment spots, 
leave scars from inflamma- flat warts, atrophic scar- 
tory destruction. ring, telangiectases and new 

growths. 
Lesions are excited by sun The sun has no special influ- 
and other atmospheric in- ence after the first freckle- 
fluences. like outbreak, and even then 

there is no proof that it is 
due to the sun. 

Pustular syphilids in the secondary stage might easily be mis- 
taken for it, but pustular eruptions only occur in severe forms 
of syphilis, would not be limited to the exposed parts of the 
body, and other signs of syphilis, past or present, would cer- 
tainly be present in such a case; then the history and date of 
onset of the two diseases would be quite different, and there 
would be no annual summer recurrences. If cases like those 
of Unna's, in which there was no scarring and the eruption 
was not limited to exposed parts, are to be reckoned in the 
same category, the points to be relied on would be: early com- 
mencement, annual summer recurrences, especially after sun 
exposure throughout childhood, the rash consisting of slight 
pustular erythema and non-suppurating bullae or vesicles, pain- 
ful but not pruritic, with slight nervous and digestive disturb- 
ances, such as anorexia and sleeplessness, gradual spontaneous 
tendency to amelioration at puberty, and cure at or before 
twenty-five years old. 

Prognosis. — This is unsatisfactory. All that can be prom- 
ised are intervals of freedom in the cold weather, with lessened 
severity at puberty, and, with a few exceptions, cure at adult 
age. 

Treatment. — The prophylactic treatment is obviously to 
guard the patient from exposure to the sun, and even artificial 
heat on the one hand, and against cold or boisterous winds on 
the other. All irritant applications to the skin should also be 



346 DISEASES OF THE SKIN. 

avoided. Internally, as in other recurrent bullous eruptions, 
arsenic should certainly be tried, and in one of my cases salicin 
15 grains three times a day had a marked controlling effect. If 
these fail, quinine or belladonna, or the two combined, are 
worthy of trial. When the eruption is out I should puncture 
each vesicle as early as possible, and apply iodoform powder, 
or paint on a solution of it in ether, and thus hope to avoid sub- 
sequent scars. Unna's second case derived benefit from ich- 
thyol soap. 

After rupture of the vesicles or bullae the crusts should be 
softened in carbolized oil 1 in 40, and the exposed surface 
dressed with acidi borici gr. 20, iodoformi gr. 5, creolini TTLv, 
adip. benz. 5J, ft. ung. Zinc and ichthyol and zinc and resorcin 
pastes are recommended by Buri and Brooke. Applications to 
cut off the actinic rays, such as tannate of silica, watery solu- 
tion of bisulphate of quinine, with glycerin and curcuma, have 
been tried by Unna without success. 

DERMATITIS RECURRENS (A) ^STIVALIS AND 
(B) HIEMALIS. 

These eruptions are etiologically allied to Hydroa aestivalis, 
but are morphologically different. 

There appears, however, to be no essential difference in many 
of the cases whether they come out in summer or winter. 
Hutchinson first described Recurring Summer Eruptions 
under the name of Summer Prurigo,* which now he himself 
admits is inappropriate, as the itching is not the most promi- 
nent symptom in all cases, but there is a group to which that 
title is sufficiently suitable. 

The eruption begins in infancy or childhood, seldom after 
puberty, and recurs until adult life; nearly all cases get well 
between twenty and thirty. In most cases the recurrences are 
chiefly in the summer, the patient being free, or almost free, in 
the winter; in a few cases of a similar morphology the reverse 
is the case. In the one set the sun's rays are the chief exciting 

* Sydenham Society's Atlas, Plate XXXVIII., and clinical lecture on 
" Summer Prurigo." Hutchinson's " Rare Diseases of the Skin," p. 126, 
Clin. Soc. Trans , vol. xxii. (1889), p. 82. "A Clinical Study of some 
Winter and Summer Recurring Eruptions," by H. Radcliffe Crocker, 
Brit. Jour. Derm., vol. xii. (1900), p. 39. 



DERMATITIS RECURRENS. 347 

factor, even sometimes without direct exposure, while cold 
winds also produce the eruption, but in a minor degree. In the 
other set the cold of winter is the main cause, but direct sun 
exposure has also a bad influence. Thus the most sensitive 
subjects are scarcely ever free for long together. 

In most instances the eruption is confined to the face, neck, 
and upper extremities, and is always most developed there; but 
in the most strongly marked cases it affects the whole body 
surface, except the palms, soles, scalp, and flexures. It tends 
to improve when the patient reaches puberty, unless it has be- 
gun later than usual, and some of the cases have got quite well 
when adult life was reached. 

In the majority of cases the eruption is papulo-vesicular, but 
some are vesiculo-pustular and others papulo-erythematous. 
In the commoner class of cases the eruption consists of pale 
red conical papules, and in the center of some are minute collec- 
tions of clear fluid resembling an abortive acne. They do not, 
however, tend to become pustules, but generally leave behind 
minute shallow scars. Slight edema of the affected limbs may 
occur at the height of the attack. The papules itch moderately 
at night, and the scratching may slightly modify the eruption, 
producing a small amount of scabbing at the apex of the papule. 
When the disease is of long standing the scars of successive at- 
tacks may produce a general mottled appearance of the surface. 
In two sisters under my care for six years one began at the age 
of seven, the other when nineteen. The eldest got well when 
she was twenty-six; the younger was much better at the age of 
twenty-one. In neither was there any scarring, but the itching 
was sometimes rather severe. 

In other cases the papules are broader and flatter and the 
vesicles larger, from a millet seed to a hemp seed. In others, 
again, the lesion is nearly all vesicular except a narrow areola, 
while sometimes the vesicles may become pustules. Again, the 
vesicular element may be suppressed and only erythematous 
papules, conical or obtuse, be present. Diffuse erythema and 
diffuse urticaria has recurred in a similar way. Cases showing 
other variations are described in my paper, and also pustular 
and erythematous eruptions evidently belonging to the same 
category, but coming out in cold weather and being in abey- 
ance during the summer. 



348 DISEASES OF THE SKIN. 

In the summer prurigo type, in the great majority of cases, 
the eruption is on the face, where it is worst, the upper part of 
the neck, the ears, and slightly on the back of the hands and 
forearms. It consists of convex papules, pale red, an eighth 
of an inch across, and from scratching they often have a small 
scab at the apex. (In several cases under my care it has begun 
at nine or ten years old.) The itching is often severe in the 
summer, but the eruption does not itch much in winter, and the 
scabbing is then absent and the papules paler and less promi- 
nent. Although closely crowded together, they are almost 
always discrete, and except for position, remarkably like true 
prurigo. 

Etiology. — This is obscure. Both sexes are liable to it, and 
the disease is one of infancy or childhood. One case followed 
measles; one followed shortly after menstruation (aet. eight 
years). In two of my cases digestive disturbances would 
sometimes determine an attack as well as sun and wind. In 
another, a boy, the eruption began soon after a dog-bite on the 
end of the nose. Two of them began in adult life. In one, a 
farmer, it commenced when he was twenty, and it had lasted 
fourteen years when I saw him; the eruption began with itch- 
ing and was followed by blisters. In another, a lady, it began 
at twenty-four, and was determined by exposure to sun and 
wind. The eruption came out as a small blister with great 
irritation, and dried up, but the spot lasted six weeks. 

Pathology. — All these eruptions appear to be of angio- 
neurotic origin, and a large proportion of the cases show 
a congenital predisposition or vulnerability. The varia- 
tion in the morphology depends on the idiosyncrasy of the 
patient. 

Diagnosis. — The disease resembles hydroa aestivalis in being 
a disease of early life which recurs every summer, and tends to 
improve as the patient grows up. The limitation of the erup- 
tion to the exposed regions is less absolute, and the subsequent 
scarring is very slight in comparison, while itching is more 
marked. The eruption is more variable in its characters, and 
vesiculation, if present, is on a much smaller scale, a pin's head 
to a hemp seed being the usual range. There is no tendency 
to group. The summer prurigo cases differ from true prurigo 
in not commencing until about nine or ten, in their localization, 



DERMATITIS RECURRENS. 



349 



and being worse on the face where prurigo is least developed, 
and in being always aggravated in the summer. 

Treatment. — Most of Hutchinson's cases improved under 
arsenic, though some required doses of six or seven minims. 
Locally, a lead and mercury ointment was successful in giving 
relief. Two of my cases improved most by attention to the 
digestive organs, regulating the bowels with alkaline or acid 
stomachic mixtures as required. The elder had small doses of 
arseniate of soda at the last, added to the alkaline laxative, with 
benefit. In the younger and more obstinate case combating 
the chronic constipation was the chief element of success. Sev- 
eral of the other cases had disordered digestion, but where this 
is absent arsenic should be tried. Salicin in one of my cases 
had a controlling, but not a curative, effect. In the summer 
prurigo type a solution of protargol, five grains to the ounce, 
painted on two or three times a day, gave most relief to the 
itching, and therefore prevented scratching and its aggrava- 
tions; greasy applications always increased the itching in my 
cases. Ichthyol internally seemed to do some good. 

B. Dermatitis hiemalis was first described by Duhring, but 
Corlett * has written a good paper on it, and described it as 
follows : " The eruption is characterized by variously-sized 
round, or as involution proceeds horseshoe-shaped patches, 
which are slightly, sometimes markedly, thickened, having an 
abrupt, well-defined margin, and a dusky red or slightly erythe- 
matous color. At first vesicles are present, which easily rup- 
ture, leaving denuded, weeping, irregular pin's-head to lentil- 
sized surfaces, whose color is perceptibly stronger than the 
surrounding patch, and may be likened to a raw ham tint. The 
disease at this time often presents a striking resemblance to 
herpes. Later the patch takes on a faded rose-colored hue, 
and becomes covered with a thin layer of adherent scales, when 
it might easily be mistaken for lupus erythematosus, but it does 
not spread at the periphery. This may mark the subsidence 
of an annual attack, or after many years the eruption may 
assume this form. The distribution is on the back of the 

* " Cold as an Etiological Factor in Diseases of the Skin," by W. Cor- 
lett. Jour, of Cut. and Gen.-Ur. Dis., vol. xii. (1894), p. 458. Colored 
plate. Also Trans. Third Inter. Cong.. 1896, p. 622. 



350 DISEASES OF THE SKItf 

hands, occasionally of the feet also." I have only seen one 
case which at all corresponds to this description, but the winters 
in America are much more severe than here. Nothing ex- 
cept protection from exposure to cold appears to be of any 
avail. 

Acrodermatitis pustulosa hiemalis is the name I have ten- 
tatively given to a disease of which I have seen three instances, 
and which presents several resemblances to Barthelemy's 
folliclis. 

The lesions are all excited or kept up by cold, affect the 
hands only, especially about the knuckles and sides of the fin- 
gers, and take the form of indolent indurated papulo-pustules, 
isolated, and few in number at a time; but the disease as a 
whole persists by a succession of lesions throughout the winter 
and early spring. 

They begin as hard, brown, large pin's-head points, but later 
as if there was a " thorn in the flesh " ; if pricked early, watery 
fluid issues, but later matter forms round the peg, and the 
whole is on a red raised base the size of a large pea. The cen- 
tral portion comes away and leaves a hole which heals very 
slowly and leaves a scar. A few form indurated red nodules 
without suppuration. These cases resemble folliclis in the 
character of the individual lesions, in a slight tendency to 
group, and in leaving punched-out pigmented scars. In one of 
my cases there was evidence of tuberculosis, which has been 
present in several cases of folliclis. The differences are their 
limitation to the fingers, their association with a feeble circula- 
tion, and being excited by cold weather. 

In folliclis the lesions are in large numbers, chiefly on the 
limbs, especially at the joints, and while they attack the hands, 
the palms and backs are largely affected as well as the fingers. 
Still, as the lesions appear to be identical, it may be only a win- 
ter variant of folliclis. C. W. Allen * of New York records a 
case of somewhat similar characters. It attacked the hands 
and feet, including the palms and soles, but did not extend 
above the ankles and wrists. The lesions began as erythema- 
tous spots, which soon became nodular, and in a few weeks or 
months they underwent a central necrosis and left a depressed 
*Amer. Jour. Cut. and Gen. -Ur. Dzs., vol. xvi. (1898), p. 227. 



IMPETIGO HERPETIFORMIS. 35I 

cicatrix. There was evidence in the man of gout, but not of 
phthisis. 

In December, 1891, Cavafy * showed a case at the Dermato- 
logical Society of a young woman, set. twenty-one, with the 
" chilblain circulation," but who seldom had chilblains, but 
every winter for several years was subject to an eruption on the 
fingers of indolent inflammatory lesions, slightly vesicular at 
first, but which were a little later convex, split-pea-sized, red 
papules with a solid horny plug in the center, giving them a 
somewhat warty appearance; they had no vascular points in 
the center, and went away entirely in the summer. This is 
evidently the same affection as that just described. 

The administration of nitro-glycerin tabloids and rubbing in 
unguentum iodi produced improvement in two of my cases, and 
one seemed to be cured by taking thiol gr. v. in pill three times 
a day for a considerable time. Vasogen iodin would probably 
be an improvement on unguentum iodi. 

IMPETIGO HERPETIFORMIS (Hebra). 

Definition. — An inflammatory disease, characterized by the 
formation of groups of small pustules, attended with severe 
constitutional symptoms. 

No case of this disease, that I am aware of, has been recorded 
in England, and most of the American cases are regarded as 
pustular forms of dermatitis herpetiformis. 

Heitzmann's and Fordyce's are possibly true examples of 
this rare and formidable disease, but their identity is by no 
means unchallengeable; at the same time, with such a rare dis- 
ease we are apt at first to form too narrow a conception of its 
clinical possibilities, which often have to be widened as experi- 
ence grows. 

Whitehouse's f case, in a male set. thirty-nine, appears to 
have been of the classical type. 

It is mainly to Hebra J and Kaposi that we are indebted for 

* Published in full in Brit. Jour. Derm., vol. iv. (1892), p. 1. 

f H. H. Whitehouse of New York. Amer. Jour. Cut. and Gen.- Ur in. 
Dis., vol. xvi., April, 1898. 

X Hebra' s Atlas, Lief, ix.. Plates IX. and X. Reproduced in Kaposi's 
Hand Atlas, Plates CXXVII. and CXXVIII., additionally illustrated in 
Plates CXXIX. to CXXXIII.; CXXXII. was in a male. 



352 DISEASES OF THE SKIN. 

what we know of this disease, and from their account, founded 
on five cases, and from a monograph by Kaposi,* the following 
description is taken. 

Symptoms. — The eruption consists of pin's-head-sized, super- 
ficial pustules, sometimes isolated, but generally densely 
crowded into groups half an inch across, often circular in shape, 
the central pustules of which dry up after a time, while fresh 
ones are formed at the periphery ; by this means, and by coales- 
cence with neighboring groups, large areas are implicated. 
The contents are pustular from the commencement, at first 
only opaque, but later greenish-yellow, until they dry up into 
dirty-brown crusts, which enlarge by the accretion of other 
pustules at the periphery. The commencement of the eruption 
is on the inner side of the thighs and groins, round the navel, 
on the breasts, in the axillae, and the oral mucous membrane, 
where it may even precede the skin eruptions. As fresh groups 
and isolated pustules are continually developing in crops, the 
whole body surface may be involved in three or four months; 
the skin is then hot and swollen, with crusted, fissured, and ex- 
coriated patches, here and there still bordered by pustules; and 
even on the tongue, in one case, were circumscribed gray 
plaques depressed in the center. 

Rigors and high fever precede the onset of the eruption and 
of each outbreak, which are immediately followed by a fall of 
temperature, so that the general symptoms are those of a re- 
mittent fever, with dry tongue, intercurrent rigors, loose 
bowels, high-colored urine, with increased urea, but no albumin 
until late in the disease. It has ended fatally in all the female 
but one, of Kaposi's cases, and in this there were many relapses, 
while two recovered after several attacks, but succumbed to a 
later one. Schultze's and some others of the milder type have 
also recovered. In nineteen cases the victims were pregnant 
women, and delivery had no influence for good or evil on the 
course of the disease. In some cases endometritis and peri- 
tonitis were found post mortem; the others afforded no expla- 

*" Impetigo Herpetiformis," Kaposi, Viertelj './. Derm. u. Syft/i.,vo\. 
xiv. (1887), p. 273; highly illustrated with colored plates. See also " De 
l'lmpetigo Herpetiformes' Dubreuilh, Ann. de Derm., vol. iii. (1892), p. 
353, who reports another fatal ease in a male set. fifty-three, and gives a 
general review and list of cases— seventeen in all. About a dozen cases 
have been added to this number. 



IMPETIGO HERPETIFORMIS. 353 

nation of the cause of death. The twelfth case, under Kaposi, 
was a young man. The disease began apparently as a severe 
intertrigo, with great general disturbance; it spread over the 
abdomen, and smaller patches came elsewhere; he gradually 
sank, and post mortem there was general peritonitis, with 
effusion. 

Dubreuilh's, Whitehouse's, Tommasoli's, Pollock's and 
Rille's, and Gunsett's cases were also men; Gunsett's case re- 
covered. Whitehouse's case and Breier's cases were pre- 
ceded by what appeared to be only severe eczema, and Rille's, a 
lad of seventeen, by an iodoform dermatitis. This rather 
favors Hallopeau's view that there is a purulent infection of 
the skin. Gunsett's case,* from Wolff's clinic, was a man set. 
thirty-three. The disease began suddenly with rigors and 
fever, the eruption began on the face, then attacked the mouth 
and pharynx, and then the groins; thence it spread all over the 
body except the scalp. Under the administration of quinine he 
recovered in about two months from the onset. 

All the cases of Kaposi's type are singularly alike in the de- 
velopment and appearance of the eruption, except that in a 
few the pustules have been a little larger than he described. 
In several they have reached the size of a lentil. 

If cases such as Heitzmann's and Fordyce's are to be brought 
into the same category, then a somewhat wider symptoma- 
tology will have to be adopted. 

The pathology is doubtful. Probably it is a disease of septic 
origin, though this has been actually demonstrated in only 
about one-third of the cases, and Auspitz has called it Herpes 
pyaemicus. Neumann considered it to be a metastatic pustu- 
losis. Duhring at one time regarded it as a phase of dermatitis 
herpetiformis, but has modified his views somewhat since the 
publication of Kaposi's paper, and acknowledges that even 
Heitzmann's case does not correspond with Kaposi's descrip- 
tions. 

Unless Kaposi has given too narrow a conception of the dis- 

*Gunsett, Archiv f. Derm. u. Syfth., vol. lv. (1901), p. 337. Abs. Brit. 
Jour. Derm., vol. xiii. (1901), p. 402. He gives references to all the above- 
mentioned cases and others, 28 in all, but some are not genuine cases. 
Out of the 28, 19 were puerperal women, 1 was not pregnant, 8 were 
men. Some of the male cases recovered. 

23 



354 DISEASES OF THE SKIN. 

ease, the diagnosis would not offer much difficulty; successive 
crops of small pustules in spreading groups, with severe rigors 
and fever, especially if in a pregnant woman, would be suffi- 
cient to characterize it. It resembles dermatitis herpetiformis 
in the groups, the tendency to form circles and to spread 
peripherally, but differs from it in the lesions being very small 
and pustular from the beginning, which is very exceptional in 
dermatitis herpetiformis,* in the absence of erythema and of 
severe pruritus, and in the presence of severe general symp- 
toms, with a fatal result in nearly all cases. In the last par- 
ticulars, in the positions most involved, and in the affection of 
the oral mucous membrane sometimes preceding the skin 
lesions, it recalls pemphigus vegetans. It should be compared 
with Hallopeau's cases of pyodermites vegetantes, with very 
similar eruption, but mild course. 

Treatment. — None has been successful hitherto; continuous 
baths, where practicable, would give relief and lower the tem- 
perature. Antiphlogistic treatment has been tried in vain. I 
should be inclined to treat it as pyemic, and give five to ten 
grains of hydrochlorate of quinine every four hours, and a 
highly supporting dietary, with alcohol in some cases. 

PSORIASIS.f 

Deriv. — ipajpa, the itch. 

Synonyms. — Lepra; Lepra alphos; Alphos; Psora; Fr., 
Psoriasis; Ger., Schuppenflechte; Psoriasis. 

Definition. — A chronic inflammatory disease, characterized by 
dry, red, primarily roundish patches, covered with imbricated, 
silvery, adherent scales, occurring chiefly on the extensor 
surfaces. 

*Maret, in his " Inaugural Thesis of Strasburg," 1887, and Du Mesnil 
and Marx, Archiv fur Derm, und Syph., vol. xxi. (1889), p. 657, and 
in vol. xxiii. (i8gi), p. 723, publish cases as impetigo herpetiformis, 
with relapses, but favorable course. If their view is correct Duhring's 
contention would be established, but further evidence is required 
before a decision can be arrived at. 

f Literature.— Author's Atlas, Plates XXIII. to XXVIII., illustrating 
the chief varieties, and Plate XC, Figs 2, 5, 6, 7, as it affects the nails. 
Syden. Soc, Plate XIV., which shows a high degree of crusting, and 
Plate XVII., as it affects the palm and nails, are especially good. 



PSORIASIS. 355 

Psoriasis is in most cases easily recognizable, and one of the 
most common diseases of the skin. It is the fourth in frequency 
in private,* and the fourth in hospital practice, and forms about 
seven per cent, of all cases in this country, but in Vienna and in 
America it appears to be less common than in England and 
France, viz., two and three and one-half per cent, respect- 
ively. 

There is only one kind of true psoriasis, but many qualifying 
terms have been given to the variations in its clinical aspect, 
founded chiefly on the stage of development, its localization, 
and the acute or chronic character of the inflammatory process, 
and occasionally on some complication or exaggerated feature. 

Symptoms. — A typical case has well-marked characters. 
Symmetrical in the main, it selects, in the vast majority of 
cases, the extensor surface of the limbs, especially the tips of 
the elbows and knees, and next in frequency the scalp and 
trunk. It consists of patches of very variable size, round or 
oval when small, but irregular when large; they possess sharply 
defined borders, so that they stand out prominently from the 
healthy skin, and are covered more or less completely by im- 
bricated silvery or grayish-white, scaly, adherent crusts, placed 
upon slightly raised plateaux of a bright red color at first, but 
in cases of long standing of a duller hue. This is best seen 
when the scales are picked off, which exposes to view a num- 
ber of bright red dots, which bleed easily, and are the apices of 
the hyperemic papillae. A lens is often necessary to see these 
red points, and the scales must be completely removed. 

The eruption is dry from the commencement, itches more or 
less, according to its development and the activity of the 
hyperemia. But the irritation is usually much less than in 
eczema, and there is no pain unless the eruption is over the 
joints and the movements produce fissuring. In the majority 
of young cases the patients appear to be in good health, often 
with bright, clear, ruddy complexions, justifying Hebra's 
dictum, that " psoriasis is a disease of the healthy," but, like 
most aphorisms, this must not be taken too literally, and espe- 
cially if the first attack occurs after thirty. 

*Inmy private practice it is six per cent, and in McCall Anderson's ten. 
Bulkley gives four and five per cent, for his public and private practice 
respectively in New York. 



356 DISEASES OF THE SKIN. 

Primary Plaque. — In a considerable proportion of cases, if 
the mode of development of the first attack is investigated, it 
will be found that the disease commenced in one or two patches 
close together, which slowly enlarged and coalesced into a 
plaque, which remained single for weeks, months, or even 
years before multiplication took place. This may occur in two 
ways, either slowly, the patches coming out singly and unsym- 
metrically and usually not far from the original patch, or more 
rapidly and then symmetrically in distant points, such as the 
elbows and knees, or with generalization. This mode of de- 
velopment is like that of pityriasis rosea, but is not observed in 
recurrences, which may be widespread and symmetrical from 
the first. Once established, the course is chronic, varying, 
when untreated, from months to years; but there are nearly 
always remissions or intermissions. If removed entirely, its 
recurrence is only a question of time, some patients having 
one or two attacks a year, while others go free for much longer 
intervals and a very few cease to recur at all. The eruption 
leaves only a transitory redness, or slight pigmentation, unless 
the patch has been very chronic, is below the knee, or has been 
treated with arsenic, which often produces dark staining on the 
site of the patches. 

Variations. — According to the intensity of the .disease, the 
size, shape, and stage of the patches, and the amount of scales 
upon them, etc., the earlier writers made varieties and chris- 
tened them with different names. These, perhaps, are of some 
slight use to the specialist to express briefly the aspect of the 
case, but are useless lumber to the student, and are only ex- 
plained here as they are still used by some writers. 

Psoriasis commences as a small pin's-head-sized flat papule, 
which speedily becomes capped with white scales (P. punctata). 
The papule enlarges at the margin, and when about a quarter 
of an inch across looks " like drops of mortar on the skin " 
P. guttata) ; continuing to enlarge, discoid patches of various 
sizes up to about two inches are formed (P. nummularis, 
discoidea). The coalescence of several patches from different 
centers produces large, irregular patches, or even sheets of 
eruption, covering the greater part of the limb or trunk 
(P. diffusa), and when all over the body P. universalis.* 
* It is probably never absolutely universal, but Hebra seemed to think 



PSORIASIS. 357 

The disease may stop for some time, or never go beyond any 
one of the stages above mentioned. 

Involution of the disease always commences in the center; 
thus in a round patch a ring is produced (P. circinata) ; when 
it happens in a compound patch, gyrate lines are formed 
(P. gyrata).* As the healing process progresses, the ring gets 
narrower, then broken, and, finally, the broken parts disappear. 
In this case, then, it is an indication of involution, but it may 
occur also in evolution upon the trunk, and form rings and 
festoons from the first, apparently following the normal ar- 
rangement of the hair follicles; the component papules, which 
begin at the follicles, coalesce into rings, and these rings meet- 
ing, break at the place of contact and form festoons. In this 
form the disease spreads at the margin as in the patches, but 
involution goes on pari passu, and so the rings enlarge; but the 
strip of disease is not widened. When a healthy process sets in 
the evolution stops, the ring gets broken, and the whole gradu- 
ally disappears. This ringed mode of development, which is 
rarely seen on the limbs, was called Lepra by Willan, a term 
now restricted to leprosy. 

A few other names remain to be explained. Very obstinate 
cases, where the skin is much thickened and fissured, with large 
adherent scales, are P. inveterata ; where the scales adhere so 
as to form much-raised, conical heaps, P. rupioides;! where 
there is a little pus underneath the crusts, a rare event, 
P. empyodes. I 

that such a condition exists. In Kaposi's Hand Atlas a case with this 
designation had small areas of normal skin. I have never seen a case 
without some intervals of healthy skin, though I have, of course, seen 
many cases which have passed into pityriasis rubra. 

* Plate XXVII. of my Atlas illustrates an evolution eruption, and Plate 
XXIV. of the St. Louis Atlas an involution case of very similar aspect. 

In a case recorded by Gassmann the patient had numerous circles and 
gyri of very small size, forming an arabesque pattern. He quotes Jadas- 
sohn, his chief, as having had three similar cases. 

fl have met with an extreme instance in a child of five, in which the 
limpet-shell resemblance was exact in silvery adherent scales. It was 
not more difficult to cure than the usual form. In a case reported by 
Gassmann with rupioid eruption on the trunk, on the scalp the crusts 
formed veritable horns. An extreme case was seen by Kaposi with 
verrucose tumors on the palms and soles, and the scalp was almost bald 
with tumors. — Annates de Der7n. et de Svp/i., vol. iv. (1893), p. 109. 

X A case of Hallopeau's simulated bullae in some of the lesions. 



35 8 DISEASES OF THE SKIN. 

In P. acuta there are bright red patches, less defined at the 
margin than usual, or there may be large areas; the scales are 
thin and papery, being thrown off so rapidly that they have no 
time to aggregate into masses. The part is hot and tender, 
itches severely, and very little irritation will produce discharge 
constituting the P. eczemateux of Devergie, which is seen 
mainly on the forearms and legs. P. acuta sometimes goes 
on to pityriasis rubra. 

It must be borne in mind that the usual appearances may be 
modified from various causes. Thus, there may be hardly any 
scales, owing to previous treatment, of which the patient often 
makes no mention until questioned. In chronic alcoholics the 
patches often assume a deep purplish-red color and the scales 
shell off easily; or, owing to the presence of unusual irritability, 
the patches may be scratched into an ecthymatous condition. 
In a case of mine with rheumatoid arthritis the crusts assumed 
a horny character. The disease may be arrested at almost any 
of the developing stages, c. g., the eruption may be punctate or 
guttate throughout its whole course, even when the disease is 
otherwise so severe that every region is involved. 

Position on the body also modifies the disease. When on the 
scalp it only leads to loss of hair when it is more than usually 
acute; as a rule, it interferes remarkably little with the growth 
of the hair, and the scalp may be patchily scurfy, while on the 
borders of the hair it is often such a bright red as to be mis- 
taken for eczema; but the abrupt termination of the diseased 
area, and the absence of discharge, should lead to the right con- 
clusion. When on the scrotum the skin is often fissured with 
much swelling, redness, induration, and thin secretion; there 
are tenderness, pain, and irritation. 

On the palms and soles it is rare, and almost invariably asso- 
ciated with manifestations elsewhere; when it does occur there, 
raised patches with scaly crusts are seldom formed, but the 
horny layer is thickened in small areas, and by splitting pro- 
duces whitish worm-eaten-looking spots. In one of my cases, 
without any eruption elsewhere, the palms were covered with 
small patches about a quarter of an inch across, without much 
thickening, and covered with a single layer of white scales. The 
patient had had two or three attacks; had often been accused 
of, and treated for, syphilis, without effect on the patches, which 



PSORIASIS. 359 

got well under ordinary psoriasis treatment. One of my pa- 
tients, a girl, had had several attacks of general psoriasis, which 
always commenced on the palms and soles with diffuse redness 
followed by rapid exfoliation of the epidermis. 

The great majority of cases of so-called palmar or plantar 
psoriasis are of syphilitic origin, or else are eczema palmare. I 
have, however, met with one extreme instance, in which it was 
limited to the left hand for many years, especially affecting the 
palm. There were heaped-up silvery scales all over the palmar 
aspect, well-defined scaly patches on the knuckles and wrist, 
but the disease had never affected any other part except the 
right hand at an earlier period. Cavafy showed a similar case 
to the Dermatological Society in July, 1894. Psoriasis is occa- 
sionally unilateral even when the patches are numerous, as in 
Kusnitsky's case.* In Cavafy's the disease was limited to the 
right forearm and hand for twenty years, having begun on the 
palm, also a single patch may exist for a long time in the first 
attack, as already shown, and then there may be a rather rapid 
development of numerous patches. 

P. Striata. It has also been seen in a band or striate form 
down the back of the thigh and leg, a distribution seen more 
frequently in lichen planus. \ Hallopeau and Constensouer 
record one case and J. Heller another. % Scratching will some- 
times determine a linear development. Thibierge's case § had 
the same distribution, and in addition the arm was affected in 
the course of the musculo-cutaneous nerve. Sciatica had pre- 
ceded the eruption on the lower limb. He quotes Besnier, 
Polotebnoff, and Bourdillon for similar cases following 
neuralgia. 

Psoriasis may attack scars, tattoo marks, vaccination scars, 
etc. Morel-Lavallee || relates an interesting case in many par- 
ticulars of a gouty man who fell on his elbows, and psoriasis 
developed there, as the skin was healing, and then on the 
palms, soles, and scalp. 

*" Etiology and Pathology of Psoriasis," Archiv f. Derm. u. Syph.\ 
vol. xxxviii. (1897), p. 405, plate. 

f Annates de Derm, et de Syp/i., vol. ix. (1898), p. 1120. 
^Heller, Deutsch. med. Wochensch., 1898, No. 52. 
§Thibierge, Annates vol. iv. (1893), p. 1195. 
\ Annates, vol. ii. (1891), p. 463. 



3 6o DISEASES OF THE SKIN. 

Mucous Membranes. — These are rarely involved in psoriasis. 
There are only a few cases recorded. Sachs's * is an example 
of a patch on the inner surface of the lower eyelid. Hutchin- 
sonf records a case less conclusive but with more extensive 
and serious lesions of the mouth, and another with symmetrical 
filmy patches on the tongue. Bucco-lingual leukoplakia has 
been several times observed associated with psoriasis, but it is 
due to so many causes that it cannot be proved to be due to the 
psoriasis. J. Schiitz^: of Frankfurt in recording two such 
cases gives a large number of references of psoriasis associated 
with lesions of mucous membranes. 

The nails of the fingers and toes may be affected in varying 
degree, either alone, or more often associated with the disease 
elsewhere. Several are usually symmetrically involved, some- 
times one, but rarely all, and it may begin at any part of the 
nail. Sometimes a small patch of psoriasis may be seen under- 
neath the nail, which loses its polish, becomes opaque, thick- 
ened, pitted, furrowed transversely, of a dirty fawn or brown 
color; the nail splits, breaks, especially at the end, and may get 
detached from its bed from the accumulation of epidermis be- 
neath it; or the disease, as Mr. Hutchinson well describes it, 
may " begin by a little patch of discoloration under the free 
corner of a nail, and the patch extend down one or both sides 
to the root."§ He regards this as absolutely characteristic of 
the disease; but although most commonly due to psoriasis, it 
may occur from other causes. 

The disease may remain limited to this strip of nail, but more 
often affects the whole to a greater or less degree. All the 
above characters vary in intensity, from a slight pitting without 
discoloration, up to enormous thickening and raising up of the 
nail from its bed even to half an inch in thickness, as in the 
case of palmar psoriasis just described, a case of which it may 
be mentioned that all the members of the Dermatological So- 
ciety concurred in its being of non-specific origin. It is prob- 
able that those cases which begin at the distal end are an 

*Internat. Atlas of Rare Skin Diseases, Lief, ix., Plate XXVII., Fig. 2. 

f Arc/m'es, vol. ii. (1890), p. 160; also vol. iv. (1893), p. 315. 

% Archiv f. Derm. n. Syph., vol. xlvi. (1898), p. 433. 

§ " Diseases of the Nails and their Significance as Symptoms, and Dis- 
cussion." Trans. Deriii. Soc. Great Britain and Ireland, vol. v. (1899- 
1900), p. 1. 



PSORIASIS. 361 

auto-inoculation, from scratching the body patches, but that it 
may also attack the matrix from within, and then produces 
pitting and other changes, beginning at the proximal end. 

Danlos * records a case of an alcoholic woman of fifty-two 
who had had previous attacks of the usual distribution, but in 
the last it was almost limited to the ungual phalanges of the 
fingers and toes, affecting both palmar and dorsal surfaces, and 
all the nails were ultimately shed with imperfect renewal on the 
toes, but the finger-nails grew healthily. 

Sweat duct Psoriasis. f The lesions are for the most part 
only one-eighth of an inch in diameter, but may cover a great 
part of the trunk and limbs. Although acuminate at first, they 
soon flatten out into slightly scaly spots. The scales are some- 
times not perceptible until the surface is scratched with the 
nail. This variety of P. punctata is not very rare, but has not, 
I believe, been previously differentiated. 

Follicular Psoriasis is a rare form of punctate eruption situ- 
ated at the hair follicles. The papules may be millet-seed to 
hemp-seed-sized, with scaly top, as in a case shown by S. 
Mackenzie J to the Dermatological Society, or somewhat 
larger, as in a very remarkable case of mine.§ In both of these 
cases the eruption was densely crowded and universal. They 
are lichenoid in general aspect, but do not coincide with the 
psoriasiform and lichenoid exanthem of Neisser, Jadassohn, 
etc., described under Lichen Variegatus. Tenneson regards 
lichen acuminatus as a follicular psoriasis, but the general his- 
tory and course are different. Kracht showed a case at the 
Moscow Dermatological Society in 1891, in which funnel-like 
horny pegs were inserted into the follicular orifices. 

Complications and Sequelae. — In a young man under Ka- 
posi, for over thirteen months pustules in enormous numbers 

* A 7i7i ales de Der77i., etc., vol. i. (1900), p. 737. 

f Author's Atlas, Plate XXV., Psoriasis Punctata, is an illustration. I 
have, since that was published, been able to establish the anatomical 
position of the lesion round the sweat duct. 

X Brit. Jour. Der77i., vol. xii. (1900), p. 17. 

§ Author's Atlas, Plate XXVI., Psoriasis Follicularis. Plate CCLXXXIV, 
Psoriasis Striata, in Kaposi's Hand Atlas, seems to be a similar case, 



362 



DISEASES OF THE SKIN. 



were constantly appearing in spite of treatment; a local irrita- 
tion always determined an outbreak. In exceptional cases 
deep pigmentation accompanies and follows psoriasis where no 
arsenic has been taken. I have met with one such case in a 
man with general psoriasis, which seemed on the point of de- 
veloping into a pityriasis rubra, but was checked in time; the 
whole of the eruption was a deep sepia tint, which remained 
after the psoriasis was cured. Brocq met with a case of pity- 




k& 



^V 



y 



i ' *!■*--»«,-. 



> 



Fig. 21. — a, Pin's-head papule of sweat pore Psoriasis; b, sweat pore. 
X 1 in. Ross 6 in. Tube. 



riasis rubra which became suddenly deeply pigmented, and 
Plate XXXIV. of Neumann's Atlas is called psoriasis nigra, but 
there it is in small circumscribed patches. 

Hallopeau* records the converse of this, permanent achromia 
being left on the site of the patches. I have also met with a 
case in a child resembling leukodermia. Nielssen also men- 

* Hallopeau's first case was in 1892; in 1898 he had a second case, set. 
eight years. Annates de Derm, et de Syfik., vol. ix. p. 690. In a dis- 
cussion at a congress at Munich, in 1899, Rille said he had seen ten cases, 
but some of these must have been due to chrysarobin treatment A fi- 
nales, vol. ii. (1901), p. 80. 



PSORIASIS. 363 

tions leukodermia after psoriasis, and after both arsenic and 
large doses of iodid of potassium. Temporary achromia after 
chrysarobin treatment is well known. 

Superficial scarring has remained on the site of the patches in 
very rare instances. I have seen one case following chrys- 
arobin treatment. Hutchinson * records a case in which slight 
scars were always left after each attack, but they were not per- 
manent, but relapses never attacked the old sites, and the scale 
crust was very thin and adherent, so that he never shed any 
scales. The disease was amenable to arsenic. Keloid also may 
occur; in December, 1891, Anderson showed to the Dermato- 
logical Society a boy, set. eleven, in whom keloid had developed 
on the site of what appeared to be patches of ordinary psoriasis, 
to which he had been subject for years. They were most of 
them in herpetiform groups, from a pea to a bean in size, flat, 
smooth, white, and only slightly raised. The small ones 
looked like morphea spots, but microscopically had a keloid 
structure; the larger ones had a keloid aspect also. They were 
not in any way traceable to irritating applications, which Bes- 
nierf believed to be the cause of Purdon'sJ case of keloid 
following psoriasis. 

Papillary Hypertrophy which may take a warty form is much 
less common in psoriasis than it is in lichen planus. I have 
seen it on the leg in an elderly man, and Morris had a case 
associated with striate ichthyosis hystrix, on the arm of a young 
man. Hutchinson § had an extreme case on the legs of a man 
of seventy-six, which got well under the application of creasote 
and Martin's bandages, and opium internally, to which the cure 
was ascribed, but I should attach it chiefly to the pressure of 
the bandage. Kaposi's || case was very remarkable. There 
was verrucose development on the patches all over the body 
from the first. 

Epithelioma followed this warty condition in the cases of 

* Archives, vol. iii. (1892), p. 57. Also two cases in vol. i. (1890), 
P- 273. 

f Kaposi-Besnier, vol. i., note, p. 559. 

XJour. Cut. and Ven. Dis.,vo\. i; (1883), p. 203. 

§ Archives, vol. i. (1890), pp. 374 and 375. 

|| Reported in A?inales de Derm, et de Syftk., vol. iv. (1893), p. 901. 
Plate CCLXXXIV. of his Hand Atlas probably represents this case; the 
face was severely affected. 



364 DISEASES OF THE SKIN. 

J. C. White, Hans Hebra, Pozzi, Cartaz and Hartzell,* etc. It 
occurred on one or more plaques of psoriasis, but apparently 
not preceded by papillary hypertrophy. It must be borne in 
mind that epithelioma also occurs on the warts from long- 
continued arsenical treatment for the psoriasis. In one of my 
cases, a man of seventy, the keratosis had been present fifty 
years, and one of the warts became papillomatous, and another 
epitheliomatous. Gassmann f records the case of a man who, 
having warts on his hands and a pruritic psoriasis, had an acute 
development of warts on the trunk and limbs on the site of the 
psoriasis lesions. 

Children. — Psoriasis in children differs in no way from its 
manifestations in adults, except that the patches more often 
remain small; the disease is seldom so extensive or so severe, 
the face is more frequently and exclusively affected, and the 
elbows and knees often escape, but J. Schiitz had a case of 
thirteen months old with both knees affected. I have rarely 
seen anything approaching to a general psoriasis in a child, but 
in G. F. Elliot's \ case, which began at thirteen months old r 
when he saw it, aet. eighteen months, it had spread all over the 
body, including the palms and soles. The eruption was cured 
in a fortnight with arsenic internally and 30 per cent, of am- 
moniated mercury ointment externally. No evidence of 
syphilis in the infant or its family history. An hereditary his- 
tory is, I think, to be more frequently obtained when the dis- 
ease begins in early childhood. 

Nielssen says the eruption lasts longer in children than in 
adults, but that is not my experience. 

Etiology. % — Age. — Psoriasis may occur at any age after five 

* Hartzell gives a summary of previous cases. Reprint in Syd. Soc. 
Selected Essays, vol. clxx. (1900), p. 259. 

f Archiv f. Derm. u. Syph., vol. xli. (1897), p. 317. 

% New York Med. Rec, July, 1886, p. 8. 

§ Nielssen of Copenhagen analyzed 616 cases, Monatsh. f. Derm., 
October, 1892; Syd. Soc. Trans. He found that two-fifths began before 
fifteen years. Bulkley, " Clinical Study and Analysis of 1000 Cases," 
Trans. Internal. Cong. Demi., Paris, 1889, p. 878, and "Clinical Notes 
366 Private Cases," Trans. Med. Soc, State of New York, 1895. 

Author. — Introduction to Discussion on Etiology and Pathology of 
Psoriasis at Brit. Med. Assoc, meeting, 1893. Abs. Brit. Jour. Derm., 
vol. v. (1893), p. 277, with analysis of between eight and nine hundred 
cases. 



PSORIASIS. 365 

years. It is rare under three years, and I have only seen one 
case under two years, but Kaposi had one at eight months, 
Hans Hebra at six months, Neumann at four months, Billard 
at three months, and Rille * showed a case at a society in Vienna 
where the diagnosis was not disputed, set. thirty-eight days, and 
it is said to have commenced at five or six days old. In all ex- 
cept Hebra's case there was a family predisposition. There is 
no limit at the other end of the line; my oldest case was eighty- 
one, but Wilson had one which began at eighty-five years. 
Forty per cent, are said to begin below puberty. In the 
analysis of my private cases J2 per cent, began below the age 
of thirty, the numbers below 12, between 12 and 20, and 20 to 
30 being practically equal; the decades 30 to 40 and 40 to 50 
were also equal, 22.5 per cent, together, while the other 5.5 
per cent, occurred after 50. Nielssen gave only 2 per cent, 
after 50. Thus in two-thirds of the cases the disease com- 
menced between 5 and 30 years. 

Sex. — In my private practice males and females were about 
equal, and in hospital practice females predominated as two is 
to one, but foreign statistics give a slight predominance to 
males. Probably sex as well as rank and occupation have no 
influence. 

Season. — Psoriasis is proverbial for its recrudescence in the 
spring, but on the whole, recent cases are worse in the winter, 
and older cases in the spring. It appears to be more common 
in cold and uncertain climates like our own, and in Iceland the 
proportion is 8 per cent. 

Hereditary.- — It is certainly hereditary in the sense of tissue 
proclivity, in a considerable number of cases. Rosenthal and 
Bulkley found 15 per cent, hereditary; nevertheless, the chil- 
dren of psoriasitic parents often escape, and it is rare for all 
the family to have it; I have, however, known five out of a 
family of seven affected. Like other hereditary diseases, it 
may skip a generation. Except heredity, we are still in the 
dark with regard to the etiology of psoriasis ; the patients often 
appear to be the picture of health, even when a large part of the 
body is covered. In predisposed subjects, it will, however, 
often be found, on careful search, that the patient, though ap- 

* Rille, Maladies Cutanees, vol. xl. (1899), p. 385, with analysis of 
previous infantile cases. 



366 DISEASES OF THE SKIN. 

parently well and complaining of nothing, is not up to his own 
highest standard of health. Psoriasitic women often have an 
attack determined by parturition or lactation; and any other 
depressing influence, c. g., bad feeding, etc., may have the same 
effect. Violent mental emotion, such as fear, grief, or anxiety, 
has been the immediate antecedent of even first attacks in sev- 
eral instances,* and most authors agree that it is very rare 
amongst scrofulous subjects, but Bulkley disputes this and 
thinks one-fourth of the cases are of strumous type. 

Neumann said that it did not occur in ichthyotic patients, 
but Jamieson observed an unmodified case in a xerodermatous 
subject. 

Liveing considers gout an important factor, and dis- 
tinguishes two classes of psoriasis, that of the young and that 
of the gouty; the gouty begins in adult age, is attended with 
more itching and less scales, and yields to alkalies and 
colchicum, such patients lacking the typical clear complexion. 
Personally, while admitting its influence in some cases, I do not 
assign a high place to gout as a factor, but I agree that in cases 
where the first attack occurs over thirty years of age, defective 
health, especially as regards assimilation, appears more fre- 
quently to have been a determining influence. Rheumatoid 
arthritis and other arthropathies are also factors, and in such 
cases the nails are very frequently affected, and in the rheu- 
matoid cases there is a great heaping up of the scales at points 
of pressure. 

Gowers relates three cases of psoriasis following the internal 
administration of borax in gr. 5 doses for epilepsy, and sug- 
gests that there is some etiological relation between them; they 
were all readily cured by arsenic. This observation is con- 
firmed by Liveing. Boric acid from milk is said to produce a 
furfuraceous rash chiefly attacking the head and face, and also 
a circinate scaly eruption on the limbs. It is doubtful if these 
eruptions are true psoriasis. 

Injuries, such as abrasions, sometimes determine the place of 
attack, and Kobner has shown that it may develop on the site 
of pin-pricks and Henoch that it may form on scars. 

Strong irritants also appear to be excitants. One of my pa- 
tients had a strong irritant applied to the patches on his back, a 
* Hardy related such cases. 



PSORIASIS. 367 

ring of psoriasis appeared round the patches, but at a con- 
siderable distance from them; later original patches spread 
near to the new rings, but did not coalesce. 

Vaccination. — Several instances of psoriasis developing on 
vaccination lesions are on record. Rioblanc * quoted nine 
cases and added a tenth, a soldier set. twenty-two. In Piffard's 
case bovine virus had been used. The eruption does not re- 
main localized to its starting-point, but generalizes. Cazenave 
observed it on smallpox scars. On the other hand, J. Grant f 
of Ottawa records an instance of an extensive psoriasis being 
cleared off in four weeks after vaccination. It has also been 
observed as a sequel of scarlet fever, measles, and erysipelas on 
the affected skin itself, J and has also developed on the site of 
the vesicles of herpes zoster. 

Contagion. — Practically it is not considered to be communi- 
cable, although from an infant with vaccinal psoriasis Destot § 
inoculated himself by scarifying the skin over the deltoid and 
rubbing in the scales. In two days signs of psoriasis appeared 
on the tip of the elbows, and in a fortnight the disease was well 
marked. Some months later, having got rid of his attack, he 
took arsenic as an experiment, and whilst taking it, a fresh at- 
tack of psoriasis occurred, and every May he gets a fresh out- 
break. Unna states that a nurse gave the disease to three chil- 
dren under her care; Meneau cites a case where the scalp of 
one sister was probably inoculated by the same comb as that 
used by her psoriasitic sister; Graves records a case apparently 
conveyed from master to servant; A. Cantrell records two 
series of cases suggesting the possibility of contagion, sisters 
and mothers developing the disease from another member of 
the family who had acquired it without any known family tend- 
ency. While such instances of themselves are not conclusive, 
they suggest the possibility of contagion which should be borne 
in mind, so as to look out for evidence ; but it is not sufficient as 
yet to explain away heredity as Nielssen does, by assuming 

*G. Rioblanc, Annates de Derm, et de Syph., vol. vi. (1895), p. 880. 

\ New York Med. Rec, May 2, 1896, p. 627. 

% Med. Times and Gaz., March 14, 1863, p. 283. 

%Jour. Cut. and Ven. Dis., vol. i. (1883), p. 203. Also Hallopeau's 
critique, Annates de Derm., etc., vol. ii. (1901), p. 337, in which he con- 
siders Destot's case conclusive. I have seen one case six months after 
revaccination. 



368 DISEASES OF THE SKIN. 

family contagion. Ducrey made numerous experiments to test 
inoculability, but failed entirely to reproduce the disease; but 
many admittedly inoculable diseases cannot be transmitted at 
will, e. g., molluscum contagiosum. 

Pathogeny. — This is unknown, but there are, out of many 
hypotheses, two theories, for each of which there is a good deal 
to be said. 

i. That it is primarily a neurosis of the skin, either vaso- 
motor, as Polotebnoff suggests, or that it is a tropho-neurosis, 
central or peripheral. 

2. That it is due to an organism in the tissues probably 
schizomycetic, but it is almost certainly not Lang's epidermo- 
phyton. 

In a practical work like this the question cannot be fully dis- 
cussed. I can only somewhat dogmatically state that my view 
of the hypothesis that best fits all the clinical facts is: 

i. That the disease is primarily due to a microparasite, which 
is probably very widely spread, but only grows in certain per- 
sons, and that heredity is really tissue suitability for the growth 
of the organism. 

2. That, while the parasite is probably first planted on the 
skin from without, the symmetry and often rapidly widespread 
distribution can only be accounted for on the theory that the 
parasite penetrates into the circulation and is thence distrib- 
uted. 

An analogy is to be found in pityriasis rosea, in which a pri- 
mary patch precedes the general outbreak for about ten days. 
In psoriasis, the disease being less acute at first, this mode of 
development is less easily traced, and extension is sometimes 
gradual when local infection is possible, and at others volcanic, 
when generalization through the circulation is the only theory 
which will account for it. Hallopeau, I am glad to find, is also 
an advocate of the parasitic theory, as he considers Destot's 
experiments indisputable. Unna's view, that psoriasis is one 
end of the chain of the seborrheic process, meets with little sup- 
port beyond his own circle. 

Pathology. — There is as much dispute about the pathology as 
there is about the pathogeny. The changes found in the 
affected skin are: (i) Those of moderate inflammation (cell 
exudation, connective tissue cell proliferation, and dilated ves- 



PSORIASIS. 369 

sels) in the upper part of the corium, round the hair follicles 
and sweat ducts. (2) Enormous increase of the horny layers, 
from premature conversion of the rete cells. Many investiga- 
tors have come to the conclusion that the process commences 
in the rete, and that the inflammatory changes in the corium 
are secondary, while others consider that the inflammation is 
the primary event, and the rete and horny layer hyperplasia is 
secondary. According to Auspitz and his followers, psoriasis 
is not inflammatory, but due to an anomaly of the cornification 
process, called parakeratosis. (3) Increased development of 
the rete layers, except over the papillae. (4) Great down- 
growth of the interpapillary processes, and consequent enlarge- 
ment of the papillae. 

Anatomy. — The histology of psoriasis has been investigated by myself 
and by many observers, of whom Wertheim, Neumann, Hebra, and 
Kaposi on the Continent, Robinson of New York, Thin in England, and 
Jamieson of Edinburgh may be especially mentioned, among the older 
investigators, and more recently Schutz, Unna, Kromeyer, Kuznitzky, 
Kopytowski, Munro, etc. I will first give my original description in 
comparison with contemporary observers, and then show how the most 
recent observations modify or alter the earlier ones. 

All the German investigators adopt the view of psoriasis being 
primarily an inflammation of the papillary layer. Robinson appears to 
have examined carefully all stages of the disease, and his views therefore 
are especially worthy of attention. He came to the conclusion that the 
disease begins as a hyperplasia of the rete; and Thin, from an examination 
of the border of a nummular patch, confirms his view, with which also 
Jamieson and Tilbury Fox agree. I have excised a papule no larger than 
a pin's head, where there was only a small cap of scales on the apex, and in 
the neighborhood of this papule were others, so small as to be unrecogniz- 
able by the naked eye, while the horny layers were still affected. I will 
state briefly what I have observed in these papules and in small patches, 
and point out any differences in my observations from those of others. 

In a pin's-head papule (Fig. 22), the upper two-thirds of the horny 
layers are raised into a cone, inclosing a space between themselves and 
the subjacent layers, which are still closely adherent to the rete. The 
upper layers are, as a whole, increased in thickness and separated from 
each other. In some of the meshes thus formed lie round cells, which 
stain with carmine, and are of the size and shape of nuclei of epithelium, 
which they probably are. Besides these, which are comparatively few in 
number, there are enormous numbers of minute, circular bodies with a 
central dark spot, which lie in loose clusters between the separated layers, 
but which also exist in dense masses, lying horizontally in the still adher- 
ent horny layers below. Their appearance certainly suggests that they 
are organisms of some kind, and probably have a mechanical influence 

24 



37° 



DISEASES OF THE SKIN. 



in separating the layers. As to whether they are a materies morbi of 
etiological significance, or merely grow there because the tissue is dis- 
eased, I am not yet prepared to offer an opinion. Similar bodies may 
frequently be seen in small masses on the free surface, where there are 
as yet no papules. Later on the lower layers get separated like the 
upper, but in an earlier stage, when the papule is microscopic, the horny 
layers are unaffected. 

The most striking changes are in the rete. There is considerable 
increase of thickness as a whole, except over the top of the papillae. The 




Fig. 22. — Psoriasis. A papule the size of a pin's head. 



X 125. 



a, scaly cap; b, rete mucosum considerably thickened; c, moderate cell 
effusion in the papillary layer; d, dilated blood-vessels. The cell 
effusion was rather more abundant than is depicted in the woodcut. 



interpapillary part is increased downward and transversely; this enlarge- 
ment of their boundaries downward produces an apparent increase in the 
size of the papillae. The palisade cells are, in some places, evidently pro- 
liferating, and their lower ends form fusiform projections into the papillae. 
Sometimes, too, they form more than one layer. The rete cells above 
these also give evidence of proliferation. These changes are mostly 
developed in the center of the papule, and diminish toward the periphery, 
but do not cease for some distance beyond the papule, and are more or 
less visible in the most minute papules. 

The papillae appear enlarged both in length and breadth, the blood- 
vessels are slightly dilated, and there is moderate cell infiltration around 
them, all through the papillary layer. In more advanced patches the 
vascular dilatation and cell effusion are more marked. The elevation 
of the papules is mainly due to this cell and serum effusion. For the 
most part only the upper half of the corium shows cell infiltration; this 
is the greatest round the dilated vessels, especially in the neighborhood 
of the sweat ducts and hair follicles; and not only is the infiltration more 



PSORIASIS. 



37* 



abundant round the hair follicles, but it often extends to their termina- 
tions in the deepest part of the corium. There is also proliferation of 
the cells of the follicular wall, and consequent finger-like outgrowths 
analogous to the interpapillary downgrowth of the rete. A hair follicle 
is very frequently the center of a papule. Cell effusion extends down- 
ward round the sweat ducts, and the glands also exhibit cell prolifera- 
tion, blocking up the lumen of the lobules, and producing the appearance 
of the whole gland being a uniform mass of cells. This is more frequent 
in the gland than in the ducts. In some, the minute round bodies 
described as lying between the horny layers can be seen between the 
lobules of the sweat gland. The sebaceous glands are unaffected. I 
examined carefully the parts adjacent to the papules, and endeavored to 
find whether the process began in the rete or in the corium, but I could 
never find the rete hyperplasia without the cell effusion, nor could I find 
cell effusion beyond the rete hyperplasia. 

Accordingly, I fail to find the proof of Dr. Robinson's view, that the 
process begins in the rete, though I cannot prove the contrary. Other 
points of difference are, that I find very distinct changes in the sweat 
ducts and glands, which he does not, and that cell effusion round the hair 
follicles goes much deeper than he describes. This is against one of his 
arguments in favor of the epithelium hyperplasia preceding the cell 
effusion, as, according to him, the processes of the hair follicles are 
produced beyond the cell effusion. I can quite confirm the accuracy of 
his observations in other respects. 

Organisms in the horny cells have been previously described by 
Angelucci, who stated, at the International Congress of 1881, that micro- 
cocci were present in the scales. What their significance may be 
remains to be proved, but I am not personally disposed to adopt Lang's* 
view that they are etiological. I have compared my observations thus 
closely with Robinson's, f because he is a careful observer on the earliest 
visible lesions of psoriasis, and most other investigations have been on 
more advanced lesions. In larger patches, Thin's % observation that the 
rete, or the top of the papillae, is thinned by the premature conversion of 
the rete cells into horny cells is, I believe, true, and borne out by the 
clinical facts, but does not hold good for the earliest papules. Neumann's 
statement, that prickle cells are absent in psoriasis, is also not true of the 
earlier stage of the process, according to my observations. 

Munro claims to have examined earlier papules than previous observers 
have done, but does not appear to be aware of Robinson's and my own 
observations, which were made in 1881, and described in my first edition, 
not only from a papule just recognizable by the naked eye, but on micro- 
scopic changes before there was visible elevation. 

Munro states that the superficial cavity 1 have described above con- 
tains leukocytes, and that it is therefore really a dry abscess, and claims 

* Wolff of Strasburg has shown that Lang's epidermophyton Is really 
eleidin, and disappears when the fat is soaked out of the section, 
f Robinson, New York Med. Jour., July, 1878, vol. xxviii. 
{Thin, Brit. Med. Jour., July, 30, 1881. 



372 DISEASES OF THE SKIN. 

that it is the primary lesion, and that the multiplication of these 
' ' abscesses " and the secondary hyperkeratosis make up the psoriasis 
scale crust, and that all the other changes described by previous 
observers are later and therefore secondary. My observations led me to 
believe that the rete changes precede those in the horny layers, and that 
the vascular and rete changes went on hand in hand. Munro says 
nothing about the masses of minute round bodies, too small for leukocytes, 
and I cannot say whether they are microbes or perhaps only keratobyalin 
globules, such as Wolff observed and thinks are what Lang called 
" epidermophyton," but at all events their nature should be further 
investigated. The round cells between the horny layers' Munro calls 
leukocytes I also observed, but not in such masses, but the modes of 
preparation were imperfect twenty years ago compared to now, and they 
probably fell out in preparing the sections. 

Kopytowski * claims to have anticipated Munro, but in the Russian 
language, and describes the horny layers thickened and separated by 
layers of leukocytes, diffuse or in foci; prickle cell layer also thickened, 
and also with leukocyte foci between them, and, mixed with degenerated 
epithelial cells, formed true abscesses and in some places cavities with 
serum. The other changes being those repeatedly described, inter- 
papillary processes enlarged, fusiform cells at the apex of the enlarged 
papilla?, vascular engorgement, proliferation of epithelial cells and 
ecchymoses, and, in short, inflammation of the papillary layer. He 
considers the inflammation primary, the parakeratosis secondary, and 
that the results are attained by successive attacks of inflammation. 
Unna's observations set forth the primary parakeratosis and epithelial 
growth, and the secondary vascular dilatation view; for him, thickening 
of the horny layer is the first change. He ascribes to his morococci the 
same organisms which he finds in seborrheic eczema, a pathogenic role. 
He lays stress on the almost complete disappearance of keratohyalin and. 
eleidin from the basal horny layer, with retention of most of the cell 
nucleus. He also observed layers of cells between the horny cells, 
mostly leukocytes, but thinks some are epithelial nuclei. The granular 
layer disappears at first, but is replaced at a later stage with increased 
keratohyalin. 

All agree that the silvery aspect of the scales is, as Rindfleisch pointed 
out, due to permeation with air. 

In the papillary layer the cells round the vessels are proliferated 
connective tissue cells, according to Unna, and leukocytosis emigration is 
limited in degree in the papillae and epithelium. 

The above are samples of the different views put forward, 
but on almost every point " Tot homines quot sentential " is 
true, and there is still room for the next generation of ardent 
histologists to investigate and theorize. 

* Subsequently published in the A?viales de Derm, et de Sypk., vol. x. 
(1899), p. 705. 



PSORIASIS. 373 

Diagnosis. — The usual run of cases presents no difficulty in 
diagnosis. The absence of discharge throughout its whole 
course; the position of the patches, fairly symmetrically dis- 
tributed upon the extensor surfaces, especially the elbows and 
knees; their well-defined borders; the imbricated white scales 
adherent into crusts, covering the raised, reddened base; and 
when the scales are picked off, the bright red, easily bleeding 
points, which start into view — form a group of symptoms of a 
strongly differentiating character. To these Bulkley adds the 
possibility of peeling off a thin pellicle, after all detachable 
scales have been removed. But when in one or other of the 
many phases presented by psoriasis some of the above features 
fail to be characteristically developed, unless the symptoms are 
taken as a whole, difficulties may arise in distinguishing it from 
lichen planus and lichen acuminatus, some forms of eczema, 
pityriasis rubra, squamous syphilids, seborrhea, tinea circinata, 
and lupus erythematosus. 

From Lichen Planus. — Difficulty only arises when the lichen 
planus is in patches or infiltrations. 

Psoriasis chooses the elbows and fronts of the knees; L. 
planus the flexures of the wrists and inner side of the knees or, 
even when it does appear on the extensor surface, the elbows 
are not the usual seat. 

Psoriasis is conspicuous for the quantity of its scales; L. 
planus is conspicuous for their absence or scantiness, and there 
are never scaly crusts. 

The ground color of psoriasis is a bright red, that of 
L. planus is of a bluish-red tint, unless more acute than 
usual. 

Psoriasis begins by the formation of a small, flatly convex 
papule, scaly from the first, but sometimes requiring a slight 
scratch with the nail to reveal it. The papule speedily enlarges 
by spreading at the edge into a patch. L. planus begins as an 
irregular, flat, shining, smooth papule, and the patch is formed 
by the aggregation of many papules. The lichen infiltrations, 
which are more scaly than the patches, are produced by the 
springing up of fresh papules between the patches; the large 
patches of psoriasis, by the component patches spreading at the 
periphery until they meet. The thickening of the skin is much 
less than in the lichen infiltration. 



374 DISEASES OF THE SKIN. 

Psoriasis, as a rule, leaves no staining, unless treated with 
arsenic. After L. planus, staining is always a marked feature. 

From Lichen Acnminatus. — Error may arise between the papu- 
lar stage of the lichen and psoriasis punctata, and between 
general L. acuminatus and general psoriasis; but in L. acumi- 
natus the papules are acuminate, and begin on the trunk, and 
the infiltrations are formed as in planus. When both are gen- 
eral the scales are much less flaky, but harder and more 
horny, and the thickening of the skin is much greater in the 
lichen. 

From Eczema. — As a rule, this is easy; but when eczema has 
ceased to discharge for some time, or when the inflammation 
has not been intense enough to produce discharge, there is 
occasionally great difficulty in distinguishing it from an ill- 
developed patch of psoriasis. 

Eczema prefers the flexures, and then begins as groups of 
small vesicles on an inflammatory base, but it is quite common 
on the extensor surfaces, beginning there as groups of acumi- 
nate papules which may go on to vesiculation. It is excep- 
tional not to get a history of discharge in eczema, which never 
happens in psoriasis, unless it is irritated. 

Sharp definition at the border of the patch is the rule in 
psoriasis, and is seldom seen in eczema, which shades off into 
the healthy skin. This is a very valuable help in doubtful cases. 
Eczema crusts are dried inflammatory exudation with few 
scales; psoriasis crusts are all scales. When eczema has been 
dry for some time there may be only scales, but these are not 
then heaped up into crusts. Pick off the crusts of psoriasis, 
and you get bleeding; pick off the crusts of eczema, and you 
get serous discharge. An eczema patient is very often in bad 
health; a psoriasis patient is often in good health. In eczema, 
the complexion is nearly always pale and muddy; in psoriasis, 
the complexion is usually bright and ruddy. 

When, however, there are only one or two patches of eczema, 
especially if upon the front of the leg, and there has been no 
discharge, or so little as to be unnoticed by the patient, the dis- 
tinction is by no means easy, and only to be made by careful 
consideration of every point. Some cases of hyperemic 
psoriasis limited to the scalp are very like eczema of that part; 
but in psoriasis, where the eruption extends a little beyond the 



PSORIASIS. 



375 



scalp, the edge terminates abruptly. Although intensely red, 
the surface is quite dry, while discharge would always be 
present in eczema with the same degree of redness. When an 
old patch of eczema is unusually well defined at the edge, diag- 
nosis is sometimes difficult; the fact of the patch being away 
from the usual psoriasis positions would be of value. 

From Pityriasis Rubra. — The diagnosis gives trouble only be- 
tween a pityriasis rubra of a few days' duration and an acute 
psoriasis of moderate extent, or when both have become 
general. 

The development is slow in subacute psoriasis, often taking 
months or years to become general; pityriasis rubra is very 
rapid, two or three weeks, or even less, being often sufficient to 
cover the whole body. 

Psoriasis is never absolutely universal, some intervals of 
healthy skin being always present; pityriasis rubra is nearly 
always really universal. 

The scales are thin, papery, and never in crusts in pityriasis 
rubra; they are easily detached, and do not conceal the red- 
dened skin beneath, which is generally not so thickened as in 
psoriasis. 

In the acute forms of psoriasis the distinction is more diffi- 
cult, as here there is deep redness, flaky instead of crusted scali- 
ness, and a less defined border than usual; but the extension is 
still comparatively slow, the scales are not so large or thin, nor 
so rapidly reproduced, and the disease remains with large inter- 
vals of healthy skin between, however extensive the areas 
affected may be. There is, however, always the possibility that 
this form of psoriasis may develop into pityriasis rubra, so that 
the dividing line is often a narrow one. 

From Tinea Circinata. — The few non-symmetrical patches in 
tinea circinata coming anywhere on the body, the margin at 
first papular, and the scanty scale formation, should excite sus- 
picion of the true nature of the disease, which microscopic 
examination would confirm. 

From Seborrhea of Scalp. — Psoriasis is usually in patches, 
seborrhea nearly all over the scalp; seborrhea scales are fatty 
and dirty-looking, on a non-inflamed surface. Where psoriasis 
is all over the scalp, it spreads beyond the hairy part, and its 
true nature is then evident; moreover, it is rare then not to 



37 6 DISEASES OF THE SKIN. 

find psoriasis in its other favorite seats, or at least a history 
of its having been there. The diagnosis from the various forms 
of seborrheic dermatitis is given with those forms respectively. 

From Lupus Erythematosus. — This comes usually on the 
cheeks, where psoriasis is seldom seen. The scales are scanty, 
the edge more raised, the tissues more thickened. In the early 
stage horny plugs are often formed in the patulous sebaceous 
openings, and if the disease is removed spontaneously, or by 
treatment, more or less evident scarring is left. 

From Syphilids. — Both secondary and tertiary squamous 
syphilids may be mistaken for psoriasis. Errors arise chiefly 
from laying too much stress on one or two points, instead of 
considering the symptoms as a whole. The following points in 
the secondary squamous syphilids will assist in arriving at a 
correct conclusion: 

An acquired syphilid is rare in a child, and psoriasis is rare 
under three or four years. The patches do not favor the ex- 
tensor surfaces so much as the flexor, nor are they seen at dis- 
tant parts of the body, with extensive intervals of freedom from 
disease. They are always small, seldom over half an inch in 
diameter, and there is no tendency to enlarge peripherally. 
The scales are scanty, and often dirty-looking. The color may 
be bright red at first, but in a few days a brownish-red tint is 
acquired. A fawn-colored stain is always left when the erup- 
tion subsides. The syphilid comes out in crops, and all stages 
are often present at the same time. Besides this, there are 
often concomitant eruptions of a different character, and nearly 
always corroborative evidence, such as sore throat and tongue, 
bone pains, iritis, or some other characteristic symptoms. 

I have seen patches on the front of the leg larger and more 
crusted than usual, very like ordinary psoriasis, but there were 
scaly patches on the palms and soles to aid to a right conclu- 
sion; these shelled off and left a scaly collar round the original 
site, which was quite unlike psoriasis. 

From Gyrate and Cireinate Syphilids. — These also imitate simi- 
larly shaped lesions of psoriasis. Here again the position, 
color, and scales differ as described above, and the syphilitic 
cachexia is usually well marked. 

From Tertiary Squamous Syphilids. — One form of this closely 
resembles some cases of psoriasis. Here again position may 



PSORIASIS. 377 

assist. The syphilid is much more often on the face than 
psoriasis; the edge is more raised, giving the appearance of a 
depressed center; the scales, though white, are not imbricated 
and ulceration is very liable to occur, but even without this 
some scarring and deep pigmentation are usual sequelae. The 
number of patches is seldom large, and they are not sym- 
metrically arranged. 

Prognosis. — The prognosis of psoriasis is good for any one 
attack, but bad for the disease as a whole. Although not al- 
ways easy, we can promise to remove the eruption of any one 
attack, but we know of no means of preventing recurrences, 
which are almost sure to occur, sooner or later, in at least ninety 
per cent, of the cases. The frequency of recurrence is very 
variable. In some people it is an annual event, or even more 
frequent, one attack overlapping another even while under 
treatment. In others there may be an interval of years, these 
variations happening perhaps to the same individual at different 
periods of life. Left to itself, it may go on for many years with 
remissions and exacerbations, or it may sometimes disappear 
spontaneously. 

We can, however, in some degree limit the extent of the 
eruption by timely treatment, and the maintenance of good 
health exercises an important influence in mitigating the 
severity of an attack, and even in warding it off for some time. 
For as it has been shown that any depressing influence may de- 
termine an attack in one predisposed, so averting such influ- 
ences must be of some service in prevention. Since, however, 
our efforts in this direction must often be unsuccessful, the dis- 
ease is pretty sure to recur, and we at best only lengthen the 
intervals of freedom, or diminish the severity of an attack. 
The universal form is said by Hebra to be especially obstinate, 
and occasionally fatal; probably these were cases I should call 
pityriasis rubra. I have never seen a case in which it is not 
possible to remove the eruption for a time, if the patient would 
give himself up to the treatment, though much perseverance is 
sometimes required. Failure occurs only in chronic alcoholics, 
or when the patient subordinates his cure to his business or 
social engagements. 

Treatment. — Although the eruption of psoriasis can often be 
removed by internal or external treatment singly, a judicious 



378 DISEASES OF THE SKIN. 

combination is the quicker and more effectual method, as this 
disease is frequently so obstinate as to tax all our resources and 
patience. 

Favorable cases of moderate extent take from about three 
weeks to three months to remove the eruption, the shorter 
period only being required when the patient will give himself 
up to the treatment. 

As there are, in a large number of instances, no special indi- 
cations as far as the general health is concerned, empirical 
remedies are generally resorted to, but I am firmly convinced 
that if any defect, however slight, in the surroundings or health 
of the patient can be detected, — and careful search should al- 
ways be made, — the soundest practice is always to endeavor to 
remove such defects before attempting the internal use of 
specific medicines; and in a large number of cases thus treated 
the eruption is removed without any occasion for their use. 
The direction in which the defects of health are most frequently 
found lies in those cases tending to the depression of the gen- 
eral vitality, e. g., overwork, a relaxing climate, sexual excesses, 
suckling, or other drain upon the system. Gout, rheumatoid 
arthritis, and rheumatism have a causative relation in only a 
moderate number of cases. These indications must be met as 
far as the patient's circumstances allow; but failing to find any 
of these, we fall back upon specifics. 

The general consensus of opinion points to arsenic as our 
stock remedy. It is apt, consequently, to be used far too indis- 
criminately in this disease, in which it is generally beneficial, as 
well as in many others, in which it is either useless or injurious. 
The other specifics are thyroid extract, salicin and its deriva- 
tives, and mercury. The general indications for and against 
these remedies will be given. 

Arsenic. — There are few diseases of the skin in which arsenic 
is generally considered to be so beneficial as in psoriasis, but it 
is too often most disappointing in its effect. 

Great variations exist in the effects of arsenic upon the erup- 
tion; even in the same person, it will at one time remove the 
disease, at another fail altogether. It is usually slow unless 
assisted by local treatment, and three months of full doses is 
required to give it a fair trial. Often improvement does not 
commence until a considerable quantity has been taken. With 



PSORIASIS. 



379 



regard to the patient, it is most indicated when the digestive 
organs are sound, and there is no other defect of health to 
grapple with, unless it be anemia, when arsenic would be bene- 
ficial. And as regards the psoriasis, it is likely to act best when 
the eruption is chronic and the hyperemia moderate. 

It is contra-indicated, when there is an idiosyncrasy which 
makes the patient especially intolerant of it; when there is an 
inflammatory condition of the alimentary canal (except in drop 
doses in cases of chronic gastric catarrh); and when the erup- 
tion is coming out acutely and the patches are very hyperemic, 
as it often aggravates the eruption. Itching of the eyelids, 
redness of the conjunctivae, nausea, vomiting, colicky pains, 
and diarrhea, are among the earliest symptoms which warn us 
to diminish the dose, but it need not be given up at once. As 
regards the skin, it aggravates the itching for a time in some 
cases, so as to make it almost intolerable, and not infrequently, 
fresh patches appear while taking arsenic, even while the old 
ones are subsiding. As already mentioned, pigmentation after 
the subsidence of the eruption is apt to occur in cases treated 
by arsenic. 

If given for only three or four months, the pigmentation will 
usually be localized to the site of the patches; but when given 
for very long periods, general pigmentation, general thicken- 
ing, and warty development of the palmar and plantar epi- 
dermis may ensue. It should therefore not be so long con- 
tinued, and it is, moreover, useless for the disease, as arsenic 
has no prophylactic influence, and acts only locally on the dis- 
eased area. 

The drug may be given in the form of liquor arsenicalis, 
liquor sodae arseniatis (about half the strength of liquor arsen- 
icalis), cacodylate of soda, or the Asiatic pills, which are in 
much favor abroad, and contain one-twelfth of a grain of arseni- 
ous acid. At first one pill is taken three times a day, and the 
number may be increased until ten or twelve a day are reached, 
and continued for several months. Three or four thousand have 
been taken in this way; but Kaposi said that if marked improve- 
ment had not occurred with five to six hundred pills, arsenic 
might be considered to have failed. Any colic and diarrhea 
may, to some extent, be controlled by opium. I prefer liquor 
arsenicalis because it admits of free dilution, and thus dimin- 



380 DISEASES OF THE SKIN. 

ishes the risk of gastro-intestinal derangement, which is so apt 
to ensue during the arsenical course. As another means of 
avoiding this, the English plan is to give arsenic immediately 
after meals. The Germans, however, give it before meals; but 
few English stomachs can bear it given thus, and I believe it 
has no advantage qua the skin. The dose of liquor arsenicalis 
should begin at three minims three times a day, and it may be 
increased to ten or fifteen minims a dose, if the drug is well 
borne. Much larger doses have occasionally succeeded where 
moderate ones have failed; but arsenic should always be given 
with caution, and oss of tinct. lupuli with each dose seems to 
facilitate its toleration. Great differences, however, exist in 
this respect. Some people can take large doses for months 
without any ill effects, while in others two or three minim doses 
produce so much irritation of the alimentary canal that the 
drug has to be abandoned. It should not, however, be given 
up until efforts have been made and failed to avoid these 
symptoms. 

Subcutaneous injections have been tried in some cases, and 
very good results have been obtained in from one to six weeks; 
but my personal experience is that it is too painful and incon- 
venient for daily practice, as sufficient advantages cannot be 
promised to compensate for the drawbacks. 

Cacodylate of soda is a compound of organic arsenic which 
has recently been advocated by French physicians as superior 
to the other salts of arsenic in efficacy and safety, so that, al- 
though it contains fifty-five per cent, of arsenious acid, it does 
not produce gastro-intestinal irritation or poisonous symp- 
toms even in three-grain doses. This is, however, not correct. 
Murrell gave one grain three times a day in pill, and after 
eleven doses serious symptoms were suddenly produced. A 
grain of the salt is said to contain arsenic equivalent to about 
one-tenth grain arsenious acid, or over sixty minims of 
Fowler's solution. I have given the recommended dose of 
half a grain three times a day in several cases, but after Mur- 
rell's experience shall not continue it. I have not seen any re- 
sults either good or bad, but have not given it for long together. 
If given at all, it would be wise to begin with one-sixteenth of 
a grain in solution and gradually increase it. I am not 
aware of results sufficiently satisfactory having been obtained 



PSORIASIS. 381 

to show its therapeutic superiority over the old forms of 
arsenic. 

Thyroid Extract. — This was strongly advocated by Byrom 
Bramwell for psoriasis, who gave it largely, but its drawbacks 
and uncertainty of action have considerably restricted its use. 
Norman Walker, who saw Bramwell's practice, regarded it as 
a dangerous remedy, and gives an emphatic opinion that it 
should not be used in psoriasis. I have used it largely, and if 
the following indications and contra-indications are observed 
there need be no danger in its use, and in a limited number of 
cases its action is often both efficacious and rapid. Unfortu- 
nately, one can never predicate when it will succeed even in the 
same patient, as I have several times known it remove one at- 
tack satisfactorily and quite fail in another. 

It should not be given to elderly people or to those whose 
hearts are weak, but young persons, even children, usually 
tolerate it well. It should not be given to a developing 
psoriasis, as I have seen, repeatedly, a copious increase of the 
new lesions from it. The dose should not be more than five 
grains a day to begin with, which in a week may be increased 
to ten grains and in a fortnight to fifteen grains, if it is well 
borne; five-grain tabloids are the most convenient form of giv- 
ing it. The risk of disagreeable symptoms is out of proportion 
to the advantage of taking larger doses, which should never be 
given unless the patient is in bed and under supervision. 
Bramwell, however, got up to forty tabloids a day. Headache, 
sleeplessness or giddiness, and the pulse rising over ioo° F. 
should be the signal to stop it or diminish the dose. Patients 
get thinner while taking it. Less frequent symptoms are 
nausea, vomiting, failure of breath, diarrhea, and general rheu- 
matic pains. Iodothyrin is supposed to be the active prin- 
ciple of thyroid extract, but it is doubtful whether it is any 
more efficacious than the extract. The initial dose is five 
grains. Thyroid colloid is very powerful, and it is best not to 
give it to patients going about. The initial dose is half a grain. 

Salicin and its Derivatives. — In 1895 * I first advocated the 
use of salicin and salicylates for psoriasis. Since then I have 
used them very extensively, and have found them of great 

* "Salicin and Salicylates in the Treatment of Psoriasis and some other 
Skin Affections," Lancet, June 8, 1895. 



382 DISEASES OF THE SKIN. 

value; latterly, as salicin seemed to act as well as salicylate of 
soda, I have used it almost exclusively, as it rarely disagrees, 
while salicylate of soda often does. Salicin has the advantage 
over arsenic and thyroid that it may be given in the spreading 
stage of psoriasis, and will often check it, while the other two 
are apt to increase the eruption. As far as this is concerned, it 
has no contra-indications ; while it is not always successful, it 
never seems to aggravate the disease, and the proportion of 
cures with it is higher than in the other two. In not more than 
two per cent, of the cases I have seen the papular erythema, 
which is well known to occur sometimes with salicin com- 
pounds. In a few cases I have had to stop it because it upset 
the stomach, and produced a headache or depression. To coun- 
teract the possibility of the last, I prescribe TTLij tincturae nucis 
vomicae. The dose of salicin must be an adequate one. 
I rarely commence with less than fifteen grains three times a 
day, and increase it to twenty grains; it is seldom necessary to 
go beyond this, but I have given up to sixty grains three times 
a day without bad symptoms. Under its use, in most cases, the 
patches get paler, the scales looser, and then fall off and re- 
form much less abundantly, the patch clears in the center, then 
the outer ring breaks up, and only fragments are left, which are 
best removed by local applications. It has much less effect on 
psoriasis of the scalp than elsewhere. Like everything else, it 
fails in some cases and is not a prophylactic against other at- 
tacks. Although serviceable if there are rheumatic or rheu- 
matoid symptoms present, it acts in my belief as a microbicide 
in the blood, in which salicin is said to break up into salicylic 
and carbolic acids. Stimulating local treatment should not be 
employed whilst giving salicin, but soothing applications are 
sometimes adjuvant. 

Mercury. — Mapother is a strong advocate for the administra- 
tion of mercury internally on the microbicide theory, and claims 
uniform success with it. I have not used it to any extent by 
the mouth, but in a few cases which were rebellious to all the 
other specifics and various other treatment I have succeeded in 
removing the eruption with intramuscular injections of per- 
chlorid or sozoiodolate of mercury, the latter being less painful, 
once a week in the same way as detailed in the treatment of 
syphilis, using 1-4 grain. While the slight pain and incon- 



PSORIASIS. 383 

venience of weekly injections prevent an indiscriminate use, it 
is well worth trying in obstinate cases. Brault used yellow 
oxid injections in two cases with success. 

Other Specifics. — Kaposi recommended carbolic acid in 1-2 
grain pills, five to ten daily. 

Turpentine: Tl\x to Tl\xxx three times a day I have found use- 
ful in hyperemic cases (vide Formulae Miscellaneous Mixtures 
for directions how to give it). Antimony: T1\v to TT\,x of the 
Vinum antimoniale, advocated by Hutchinson and Morris, is 
sometimes successful in acutely inflammatory cases. Diuretics y 
as acetate of potash, are often useful; while iodid of potassium, 
so strongly recommended by Greve and Boeck of Christiania 
and Haslund of Copenhagen, is also a powerful diuretic, espe- 
cially when given in the heroic doses they advocate, up to 50 
grams a day; possibly it also acts as a microbicide, but although 
good results may sometimes be obtained with it, it is not a drug 
to give indiscriminately, and if given at all, small doses should 
be given at first. It is contra-indicated where there is any renal 
or cardiac defect, as even small doses will produce severe erup- 
tions in persons with defective power of elimination. 

On the whole, what may be called the rational treatment of 
the patient, and the first four specifics described in detail, pretty 
well cover the ground, and leave but small room for these last- 
mentioned drugs. 

Local Treatment. — Local measures play a most important part 
in the treatment of psoriasis, and are alone sufficient for the 
removal of the eruption in mild cases. They are of two classes: 
first, those used to remove the scales, and so prepare the way 
for the second, which exercises a directly curative effect upon 
the diseased skin, and so prevents the renewal of the scales. 

In the first class come alkaline baths, wet packing, india 
rubber clothing, inunction with oil, vaselin, or fat, soft soap, 
and even caustics, and a six per cent, solution of salicylic acid in 
spirit. The fat, etc., requires to be well rubbed in. Many 
cases get well with one of the above methods alone, if perse- 
vered with; continuous baths in simple tepid water have also 
been successful. Much depends on the thoroughness with 
which the scales are removed. In indolent patches soft soap 
rubbed in firmly and for several minutes with wet flannel into 
each patch is one of the best methods, but it is no good to try 



384 DISEASES OF THE SKIN. 

and rub over several patches at once. Half the battle depends 
on the thoroughness with which the preliminary and curative 
agents are rubbed in. In an extensive case two or three hours 
a day can be usefully spent in the application of the different 
remedial agents. For an alkaline bath, two to four ounces of 
bicarbonate of soda are added to thirty gallons of water at a 
temperature of 95 to ioo° F., and the patient soaks in it for 
twenty minutes and rubs off the scales. It may be taken three 
times a week. After the scales have been removed, the selec- 
tion of a suitable remedy is required, and as there are a legion 
of them, the principal only are given, with some points for 
guidance as to which to employ. 

In the acutely inflammatory form, or whenever the hyperemia 
is very great, as in the cases described as P. eczemateux, the 
soothing remedies recommended in the treatment of eczma 
are alone suitable, such as continuously wrapping up the 
parts with calamin liniment, simple olive oil, or inunction 
with the latter. An excellent plan also is wrapping the 
affected part in cloths or lint soaked in the glycerin of sub- 
acetate of lead 1 to 8, and covering it with hat lining or other 
waterproof. This both soaks off the scales and diminishes 
hyperemia, and some parts get well with this alone. Alkaline 
baths are useful here also, as indeed in all stages of the erup- 
tion. 

The special remedies suitable for the less hyperemic cases 
are all microbe destroyers, and should be rubbed or scrubbed 
in, not merely laid on. 

Much experience and judgment are often required for the 
selection of the proper remedy in any particular case. The 
first object always is to remove the scales; the activity of the 
inflammation is next to be judged of, and in any case where 
there is a doubt it is always safer to use the weaker prepara- 
tions, and when the strong are thought to be suitable to employ 
them well diluted at first. Remedies, therefore, have to be con- 
sidered according to their stimulating and penetrating effect, 
since a remedy that would be most valuable for a chronic indo- 
lent patch would aggravate the eruption when it is congested. 

Frequently, patches in one part of the body require different 
treatment from patches in another; and if a fresh attack super- 
venes upon an old one, the remedies used for removing the old 



PSORIASIS. 385 

patches often aggravate the new, which probably require a 
much milder treatment. 

The convenience of patients who have to go about has also 
to be considered. A very objectionable remedy is used irregu- 
larly by the patient, who is likely to blame the doctor for the 
imperfect result. Unfortunately, many of the best remedies 
stain or smell, and if the choice between the two evils has to be 
made, most persons prefer the stain to the smell, as most of the 
eruption is out of sight. Staining preparations, on the other 
hand, are obviously unsuitable for the face or other exposed 
parts. When the eruption is very extensive ambulant treat- 
ment is generally unsatisfactory, while, if the patient can be in- 
duced to lie up, the extent is of less consequence, and the doc- 
tor is untrammeled in his selection of remedies. Obstinate as 
psoriasis often is, it is rare indeed that success in the removal 
of the eruption for a time cannot be attained by skill and per- 
severance. 

Chrysarobin* introduced by Balmanno Squire, stands first as 
the most valuable remedy we possess, but used in the strengths 
generally prescribed of 15 grains to 3j to the *j as an ointment 
or paint, is for the most part only adapted to those cases re- 
quiring strong stimulants. While very powerful and rapidly 
efficacious in suitable cases, it has a good many drawbacks at- 
tending its use, therefore the patient should always be warned 
of its probable effects, viz., an erythema of the skin, extending 
far beyond the part to which the drug is applied, attended with 
severe itching, heat, pain, and swelling; this subsides in a few 
days if the remedy be discontinued, and often even if it is not, 
leaving a dirty-looking desquamation. If used in the neighbor- 
hood of the face, conjunctivitis is apt to occur, and the 
erythema has been mistaken for erysipelas. It dyes the hair, 
nails, skin, and linen yellow, which turns to an indelible 
purplish-brown after washing, due to the alkali in the soap. 

On the other hand, the patches are removed often very 
rapidly, leaving a whiteness f on the site of the eruption for a 
short time, in sharp contrast with the skin around, which is of 
a deep red, more from staining than congestion. Some of these 

* This was formerly called chrysophanic acid, and exists in the propor- 
tion of eighty per cent, in Goa powder, 
f Author's Atlas, Plate XXXVIII. , Fig. 2. 

25 



386 DISEASES OF THE SKIN. 

disagreeable effects may, however, be often avoided by using 
Auspitz's method: 5j of pure gutta-percha is dissolved in ox of 
chloroform, this is called traumaticin;* to this 5j of chrysarobin 
is added, and after removing the scales this emulsion is painted 
on and forms a film; it is renewed every two or three days, or 
may be painted one coat over another for four days before re- 
moving the film. Besnier's modification is to paint on a solu- 
tion of chrysarobin in chloroform, and then cover it with trau- 
maticin varnish. Both methods are equally efficacious. As 
thus used the drug is only suitable for indolent patches, or after 
the hyperemia has been subdued by other means, but I have 
found it valuable in a much wider range of cases by using 
minimal doses of I, 2, or 3 grains of chrysarobin to 5J of zinc 
ointment. A grain to the ounce may be used even in most 
cases of acute psoriasis. It is wise, however, not to use it over 
a very extended surface in one region, as even this quantity will 
sometimes excite the peculiar erythema. In all doubtful cases 
try it on a small area to begin with. 

Anthrarobin and other imitations of chrysarobin are prac- 
tically failures. 

Pyrogallic Acid in the form of an ointment (from gr. 10 up to 
5j to the §j) is not quite so strong or rapidly efficacious as 
chrysarobin, but it is a very good remedy. It excites no inflam- 
mation, unless applied continuously, and even then not beyond 
the point of application ; but it stains the skin and linen, and 
may produce dryness, itching, and follicular papules or pus- 
tules. It should, moreover, only be used over a limited area at 
a time, as it may be absorbed, and would then produce 
strangury and olive-green urine, with moderate fever and 
nausea. Large doses of dilute hydrochloric acid are said to act 
as an antidote and preventive of these ill effects. 

Resorcin, in an ointment of gr. 10 to 3j to the 5j of lard or 
lanolin and vaselin, is often efficacious for an average case; it 
is odorless, but stains the nails slightly, but less than chrys- 
arobin or pyrogallic acid, and may be used for the face. In 
obstinate patches 2 or 3 grains of biniodid of mercury is a use- 
ful addition. 

Salicylic acid, gr. 15 to 5j to §j of excipient, is sometimes 

* The proper way to make this is described in Formula No. 9, Varnishes, 
as few chemists dissolve the gutta-percha enough. The British Pharma- 



PSORIASIS. 387 

valuable for obstinate patches on the scalp and knees with 
dense adherent crusts; it does not smell or stain. 

Soft Soap and Spirit. — To limited patches, as on the front of 
the knee, scrubbing well with spiritus saponatus kalinus is often 
one of the best means to adopt; and for the scalp, when not 
actively hyperemic, the same liniment rubbed in with a piece of 
flannel dipped in hot water and then in the liniment removes 
the scales, and after rinsing it off with tepid water, a mercurial 
ointment, one or two grains of perchlorid or biniodid to the 
ounce, should be rubbed in. This treatment rarely fails on the 
scalp, if the patches are not inflamed. Oil of cade is sometimes 
a useful addition to the spirit soap. Hebra's " Wilkinson's 
ointment " is a strong, but very effectual application in properly 
selected cases, especially obstinate patches on the knees. 

The mercurial ointments should of course only be used over 
a limited surface at a time. When mild stimulants only can be 
tolerated, they are most useful — hyd. ammon. gr. 10 to 3ij to §j 
of vaselin or other simple unguent; hyd. oxidum flav. in the 
same strength, or the two combined; ung. hyd. nitrat., more or 
less diluted; hyd. biniodid. gr. 3 to gr. 10 to gj. The last is a 
stronger stimulant. As they neither smell nor stain they are 
often preferable for the face, scalp, and other visible parts, and 
they may often be combined with other drugs. 

Tar. — The vast majority of cases will bear stronger stimu- 
lants, of which tar in some form is the most universally em- 
ployed. Ung. picis liquid., pure or diluted, is often effectual, 
but dirty, and smells disagreeably; less unpleasant are the 
oleum cadini, oleum fagi, oleum rusci, or creasote, oss to 3iv 
to gj, as ointments, or as lotions dissolved in spirit, with or 
without soft soap; or liquor carbonis detergens, from TTLxx to 
gj of water and upwards to the undiluted liquor, are all valuable 
remedies. Tar baths are also useful. Tar, however, has 
many disadvantages; serious constitutional symptoms, as well 
as acneiform and other eruptions of the skin, may ensue, if ab- 
sorption occurs from its vigorous employment, or from some 
idiosyncrasy of the patient. It also smells strongly and stains 
the skin. Where the patient will give himself up to treat- 
ment, an excellent plan is to paint on with a stiff brush the 

copeia uses bisulphid of carbon as a solvent, but its fecal odor is an 
insuperable objection to it. 



3 8S DISEASES OF THE SKIN. 

liquor carbonis detergens or its B. P. equivalent, liquor picis 
carbonis, and then apply compresses, under oiled silk, of 
glycerinum plumbi subacetatis, one to eight distilled water. 
The painting is done twice a day; the compresses are kept on 
night and day. 

Thymol, Naphthol fi, etc., are remedies which may be used in 
the same class of cases as those in which tar would be suitable, 
but are much more cleanly and pleasant. Thymol was intro- 
duced by myself for this purpose some years ago. It is per- 
fectly clean, being a white crystalline substance, and its odor, 
that of thyme, is not unpleasant; it is especially useful, there- 
fore, for eruptions on the face. It may be used from gr. 
15 to oiij to the §j as an ointment or as a lotion (Lotions, 
F. 14, a). 

Naphthol was introduced by Kaposi as a remedy; it is of 
about the same efficacy as thymol, may be used of the same 
strength, and in similar cases. It is equally clean, and when 
made into an ointment is almost odorless, and is thus the most 
pleasant remedy we possess for psoriasis (F., Parasiticides, No. 
8). If absorbed, it is converted into naphthol sulphate, and 
produces cloudy urine. Although decidedly useful, I have not 
so high an opinion of it as Kaposi appears to entertain. 

The nails require special treatment. Arsenic has the most 
effect of internal remedies, it appears to pick out the diseased 
tissue; locally, if the lesion is distal only, remove the morbid 
epithelium beneath the nail, and scrape the nail blade with 
broken glass. Then push beneath the nail an ointment of acid, 
salicyl. gr. 10 and upwards, ung. zinc, oleat. 5J. If the disease 
commenced proximally, push the ointment as far beneath the 
nail fold as possible, and wrap up the finger-ends in the oint- 
ment; pits and other early developments should be scraped out. 
Sabouraud's treatment for onychomycosis (which see) is also 
useful in some cases. 

The watering-places that are most beneficial in psoriasis are 
those which contain arsenic, such as Royat, La Bourboule, and 
Levico, named in ascending order of the quantity of arsenic, 
and are proportionately efficacious internally. 

Sulphur waters, such as Harrogate and Strathpeffer in 
Britain, Aix-la-Chapelle, Schinznach, and Bareges, etc., on the 
Continent. They require a good deal of judgment in adapting 



PITYRIASIS RUBRA. 389 

the strength of the baths to the character of the eruption, or it 
may be aggravated instead of relieved. 

Thermal baths, in which the prolonged immersion in warm 
weak alkaline water is the main modus operandi. Such treat- 
ment may be found at Bath, Buxton, Leuk, Aix-les-Bains, and 
many other places at home and abroad. 

In all these places success in removal of the eruption can be 
obtained in judicious hands, but the duration of freedom from 
eruption is not longer than that produced by other treatment, 
except what may be gained by the rest and diversion, change 
of climate and scene, the regular diet and living. These points, 
together with the elevation and other climatic considerations, 
must be borne in mind in selecting a spa, and some aid in this 
direction is afforded in the Appendix, 

PITYRIASIS RUBRA.* 

Synonyms. — Dermatitis exfoliativa (Wilson); Pityriasis rubra 
aigu (Devergie); Erythrodermie exfoliante (Besnier). 

Definition. — Pityriasis rubra is an inflammatory disease, in- 
volving the whole surface of the body, characterized by deep 
redness with abundant flaky desquamation. 

This disease is one of the few forms of dermatitis which be- 
come universal. My statistics give the rate of three cases in 
two thousand. It may be primary or follow some other form 
of dermatitis, be acute, chronic, or relapsing; but the general 
aspect of the skin varies but little under the different circum- 
stances. Some authors are inclined to regard it as a form of 
eczema, but the majority of cases are much more like a very 

* Literature. — Author's Atlas, Plate XXIX.; Buchanan Baxter, 
"General Exfoliative Dermatitis," Brit. Med. four. (1879), vol. ii. pp. 
79, 119; Hutchinson, "Rare Diseases of the Skin " (1879), p. 241; Pye- 
Smith, "Superficial Dermatitis," Guy's Hosp. Rep. (1881); vol. xxv. p. 
27; Percheron, " Etude sur la dermatite exfoliatrice " (Paris, 1875). The 
works of E. Wilson, Hebra, Devergie, Bazin, Hardy, may all be consulted 
with advantage. Brocq's monograph, " Etude critique et clinique sur la 
dermatite exfoliatrice generalisee " (Paris, 1882), or the analysis of it in 
Ann. de Derm, et de Syph. (1883), vol. iv. p. 90. Discussion at Paris 
International Congress, 1889, and Derm. Soc. Lond. , Brit. Jour. Demi., 
vol. x. (1898), p. 437. 



39 o DISEASES OF THE SKIN. 

acute psoriasis, and it is in its symptoms and course a separate 
affection. 

Many restrict the term pityriasis rubra to Hebra's type, and 
include all the rest under dermatitis exfoliativa, but in my 
opinion they are all branches of the same trunk. 

There are two * leading types of the disease — the large scale, 
or Wilson type, which may be primary or secondary; the small 
scale, or Hebra type. There are, however, connecting links 
between these types. The " Ritter " type of the new-born is 
perhaps a third variety. 

Symptoms. — In a typical case, often without definite symp- 
toms, except perhaps a feeling of debility and depression, the 
eruption appears suddenly, either as a diffused redness, rapidly 
spreading all over the body, and soon becoming scaly, or in the 
form of very slightly raised, well-defined red patches, which 
soon become scaly. 

They appear symmetrically in varying positions, the chest 
and limbs being perhaps the most common when there has 
been no previous eruption, but it may begin anywhere. The 
disease is, however, seldom seen at this stage. 

The eruption spreads rapidly at the edge of the lesions, and 
others forming, the whole body may become involved in from 
two days to two or three weeks, so that there is absolutely no 
sound skin anywhere. The nail substance may not be involved, 
but it is often separated from its bed, partially or entirely, by 
the accumulation of epithelium beneath, and is then thrown off. 
The hair also is shed partially or completely. The entire sur- 
face is of an intense bright red, soon assuming a deeper hue, 
but the color is partially concealed by the scales; the redness is 
uniform, and there are none f of the red puncta, which can be 
seen with a lens in psoriasis, when the scales are removed. 
Everywhere the surface is covered with thin, papery scales, 

*Brocq considers desquamative scarlatiniform erythema a benign 
primary form of it, and divides the rest into general exfoliative 
dermatitis— (a) subacute, (6) chronic, (c) infantile; and pityriasis rubra — 
(a) subacute and benign, (6) chronic malignant (type, Hebra), and (r) 
chronic benign, the last variety being put forward tentatively. Although 
no doubt cases of each type are to be found, in my opinion the sub- 
division is too elaborate and founded on too small a number of cases to 
be of practical value. 

f The case described in Hillier's handbook is an exception to this. 



PITYRIASIS RUBRA. 



391 



small upon the face, but on the body very large, free at all their 
edges, except one, perhaps, and somewhat imbricated, like scale 
armor, but never adherent into crusts. The scales are easily 
rubbed off, but are rapidly renewed, so that two or three pints 
or more may be collected in the twenty-four hours. On the 
palms and soles the skin is detached en masse or in very large 
pieces, but the redness does not show after the first exfoliation. 
With all this intense hyperemia only slightly appreciable infil- 
tration of the skin is usually present, and the surface is dry 
where the scales are detached or easily detachable, but slightly 
moist underneath, where they are more closely adherent. 

The sweat secretion is not always interfered with, and is 
sometimes profuse in parts like the axillae. There are no rha- 
gades usually, the cuticle alone splitting, and there is little or 
no itching, but there is a feeling of burning, tingling, stiffness, 
and tenderness. Once the disease is completely established, the 
appearance of the skin may undergo but little change for an 
indefinite period, but in cases that have lasted for a long time 
there may be either thickening with the so-called lichenifica- 
tion from infiltration in some parts, or thinning in others, the 
redness gets more brownish in hue, and the scales smaller. 
The tongue appears preternaturally red, and there is, no doubt, 
exfoliation here; but it has been recognized in only a few cases, 
probably on account of the moisture of the parts removing the 
epithelium as fast as it is loosened; nevertheless, transitory 
white patches have been observed on the tongue and oral 
mucous membranes. 

Variations. — In a few cases the itching is severe, and is some- 
times the first symptom to attract attention. Attacks limited 
to certain regions occur, which must be included under this 
term, though contrary to the definition and to the first ideas of 
the disease; these may ultimately develop into universal at- 
tacks; or, on the other hand, the first attack may be the most 
severe, and future attacks diminish in severity. Devergie de- 
scribes cases with fj,uid exudation in considerable amount, but 
it does not stain linen, and may not even stiffen it ; in the latter 
case it has often been compared to sweat, and possibly may 
consist largely, if not entirely, of that secretion, but in advanced 
cases the sweat glands are destroyed. The cases secondary to 
eczema are often of a moister type than the primary cases and 



392 DISEASES OF THE SKIN. 

those secondary to psoriasis. Rhagades, though not common, 
may occur, and in this sort of case the eyelids may be drawn 
down, owing to the stiffness of the skin. 

From time to time cases have been published under various 
names, signifying their most prominent features of inflam- 
matory redness and persistent desquamation, generally uni- 
versal, but occasionally partial, as in Bulkley's case, where the 
hands and feet only were invaded; the term dermatitis exfolia- 
tiva covers them all pretty well, but while they are generally 
acutely hyperemic only, they are sometimes vesicular or im- 
perfectly bullous. Bullae may, however, form in typical cases, 
and in one of mine pemphigus had been diagnosed. Harda- 
way had a case in which there were successive crops of a dozen 
at a time for a week on the thighs, abdomen, and buttock. 
Baxter, in his valuable paper, has noticed nearly all the cases 
up to date, and while they do not exactly fit in with the typical 
cases of P. rubra, all but the bullous cases approach that dis- 
ease most nearly, and it is probable that we must widen our 
conception of it. On the other hand, Duhring is inclined to 
regard them as belonging to a class of their own. 

Pigmentation, sometimes very deep, may take the place of 
the ordinary redness. This has been observed by Handford, 
Brocq, and in three cases by myself. In one of mine it was 
not true pigmentation, but due to a venous capillary congestion, 
and it was almost completely removed for a moment by 
pressure. The body was mahogany-colored, the thighs deep 
slate, the legs not quite so dark. Britton also reported a case 
at the Leeds Medico-Chirurgical Society. In another, a 
woman set. twenty-two, there was a universal slate color which 
supervened six months after the onset, and before arsenic was 
given. Both in this and Handford's case bullae had appeared 
in small numbers from time to time. The converse appears to 
be a case of S. Mackenzie, in which there was exfoliation, but 
the skin remained white. Du Castel had a case in which striae 
atrophica? followed a severe attack in a young girl. 

Another complication observed in one of my cases, a lady aet. 
thirty-five, was the formation of numerous cold abscesses. 
They formed rapidly and generally without pain, sometimes 
small and superficial, at others large and deeper, and contained 
a quantity of thick yellowish-white pus. They healed up 



PITYRIASIS RUBRA. 



393 



readily, but the succession lasted for many months. The case, 
which had been doing well, died with cerebral symptoms sug- 
gesting the possibility of a cerebral abscess. Pernet has also 
had a fatal case in an old man with similar abscesses. 

I am quite satisfied that cases of true P. rubra may be partial. 
I have also seen, in some cases, the scales quite small and 
powdery where the hyperemia has been moderate, and in others 
rather free moisture in some parts, while the rest of the body 
presented typical characters. 

The disease may begin with sudden swelling and redness, in- 
distinguishable from erysipelas, though undoubted erysipelas 
has preceded an attack. This kind of swelling rapidly subsides, 
as a rule, but it may be more permanent, though to a less ex- 
tent; brawny infiltration is also recorded; and limited thicken- 
ing of the cutis in cases of long standing is not uncommon. 
The nails may be preternaturally softened and thinned; or on 
the other hand thickened, roughened, and furrowed trans- 
versely; they may also be yellow and translucent or opaque. 
In Wallace Beatty's case there was superficial ulceration in a 
kind of. network. In a case of Hutchinson's, in which the hair 
was thrown off, when it grew again it was snow-white and re- 
mained so, but the eyebrows and lashes were pigmented. 

Vidal and Kaposi have each had a case where small patches 
of spontaneous gangrene of the skin were observed on the 
shoulders, sacrum, thighs, etc. Stephen Mackenzie had a case 
where there was general pityriasis, but no redness; as a sequel, 
pityriasis rubra pilaris has been recorded by Devergie and Til- 
bury Fox. 

Pemphigus foliaceus has supervened in a few instances; 
Pringle, among others, relates an example; Liddell also has 
had a case. 

General Symptoms. — In the majority of instances it has oc- 
curred in previously healthy subjects, and even where it has 
not been so, in many cases, the general symptoms have been 
slight and indefinite, a feeling of debility, depression, and chilli- 
ness being the most frequent. On the other hand, severe 
rigors and considerable fever, reaching to 103 F.* and even 

*Gairdner's case, and a man in U. C. H. In this case, after malaise 
and slight chilliness, a cold bath excited a severe rigor, and the eruption 
came out on the chest and legs the same night. 



394 



DISEASES OF THE SKIN. 



104 * as a night temperature, with a morning remission, have 
been noticed in a few cases in which the temperature has been 
taken regularly; this fever is usually of short duration, and 
occurs only in the first few days, subsequently falling to normal 
or subnormal; but recurrences of fever, especially in relation to 
relapses, may be kept up for months. How severe the symp- 
toms may be the following case exemplifies. A man, set. forty, 
came under my care who, in the course of seventeen years, had 
thirteen attacks, of which nine were partial and apparently 
psoriasis, the four last universal and true P. rubra. The first 
came on one year after rheumatic fever, which left no cardiac 
affection. In most of the attacks he felt languid and out of 
sorts; in the last, after having had patches on the extensor 
aspect of the limbs, just like the developed disease, for four 
months, it became universal in two days, with great prostration, 
anorexia, and slight diarrhea, with subsequent constipation. 
He was doing well, the eruption having cleared off the face 
and chest, when a return of the weakness and depression was 
rather suddenly manifested; the throat was sore, and the tem- 
perature, which had not exceeded ioo° for ten days, rose to 
102 F. Four days later an attack of sudden swelling and 
redness, indistinguishable from erysipelas of the face, occurred, 
followed by transitory improvement in the general symptoms. 
Then the pityriasis again became universal; nightly recurrent 
rigors, once amounting to a slight convulsion, set in; the tem- 
perature reached 104 F. at night, falling to ioo° F. during the 
day; there was moderate albuminuria (1-10 albumin the last 
day); considerable emaciation; typhoid condition; pulmonary 
edema, and a temperature of 106 F. an hour before death, 
which occurred fourteen days from the first change for the 
worse, and nine weeks from the disease first becoming general. 
Post mortem there was pulmonary edema, a large soft spleen, 
and a fatty liver, but nothing to account for the result. 

Other cases with the same symptoms, with the addition of 
diarrheal have been previously recorded. 

Insanity £ has developed in the course of the disease. One 
of my cases was associated with mania, and the speech was 

* Case of Hessy, U. C. H., males. 

fMary T., U. C. H., females. 

JSee Discussion on Pit. Rub., Brit. Jour. Derm., loc. cit. 



PITYRIASIS RUBRA. 



395 



slurred and almost unintelligible, like a general paralytic. The 
patient, a middle-aged lady, recovered in mind and body. A 
case of Pringle's became acutely maniacal and died, and an- 
other " went mad." 

Krafting * records a case in which there was a development 
of innumerable fusiform celled sarcomata from a pin's head to 
a pea in size. They disappeared spontaneously. 

In cases of several years' standing anemia, gradual emacia- 
tion, and exhaustion may lead to death; or an intercurrent 
malady, such as phthisis, pneumonia, or bronchitis, may usher 
in the end. 

Instead of beginning in previously healthy subjects, in sev- 
eral cases there has been a history of acute rheumatism, with 
or without consequent heart disease, and in five cases, at least, 
erysipelas or an erysipelas-like condition, has immediately pre- 
ceded the outbreak of pityriasis rubra, or an exacerbation of 
it. In most of these, however, erysipelas was probably only 
simulated. 

General enlargement of the lymphatic glands is not unusual. 

Defects of nutrition of the skin of long standing have existed 
in a few cases. 

Many have been the subjects of psoriasis, eczema, or sebor- 
rheic eczema before or at the time of the outbreak. In one f 
the head and neck were eczematous, and the trunk like P. 
rubra; in another \ psoriasis existed at the time of the outbreak 
and lasted six weeks, and as the P. rubra got better the 
psoriasis resumed its normal course. An extraordinary case, 
under my own care, was that of a young woman § with general 
scaly folliculitis, who during treatment with subcutaneous in- 
jection of arsenic developed rheumatic fever (her second at- 
tack) with peri- and endo-carditis, double iritis, and multiple 
arthritis. The skin became acutely inflamed, the whole of the 
original rash shelled off in large patches, the skin beneath was 
smooth and shiny, and then scaly, and P. rubra developed. 
The woman recovered after being almost at death's door, and 

* Annates de Der?n., vol. vi (1S95), p. 1098. 
f S. Mackenzie, Lancet. 
% Guibout, Union Medicate. 

§Her original eruption is depicted in Plate XXVI. of my Atlas, with 
the full history of her case. 



396 DISEASES OF THE SKIN. 

subsequently there was a slight return of the primary eruption. 
It is the rule in these secondary cases that the disease develops 
beneath, as it were, the original lesion, and as the pityriasis 
rubra involutes, the primary eruption resumes its course more 
or less completely. Baxter had a case developing on " lichen 
ruber." He also had a case following pityriasis capitis and 
erythema papulatum, and another in a child of six months de- 
veloping from eczema of the head and face. In my experience 
it is far more frequent after psoriasis * than any other form of 
dermatitis. It is noteworthy that nearly all these are forms of 
dermatitis which are liable to become universal, or nearly so, 
while still preserving their usual characters; but while some 
relationship is suggested, we must not conclude at once that 
the affinity is pathological, as it may be only etiological. 
Brocq f quotes a case in Vidal's clinic in which a severe attack 
of two months' duration, with intense fever, was excited by the 
too vigorous application of chrysarobin. I have also seen a 
typical case of P. rubra following the too vigorous inunction of 
ung. hydrarg.,J and one from the external use of arnica. 
These artificial cases, and those secondary to psoriasis and 
other forms of dermatitis, Brocq wishes to separate on the 
ground that they are not universal, nor of long duration; but 
this, while true of some cases, is not so of others. I have re- 
peatedly seen the most severe, absolutely universal, and fatal 
cases in this class of secondary P. rubra, and, except etio- 
logically, in every way similar to the other less common primi- 
tive cases, and it appears to me to be illogical to separate them. 

There is also a premycosic form, in which clinically the erup- 
tion is indistinguishable from ordinary P. rubra until the 
tumors appear. 

The Small Scale, or Hebra Type, of Pityriasis Rubra. — Typical 
primary cases of this kind are very rare, very slow in their de- 
velopment and course, and almost invariably fatal, but all small 
scale cases are not of this type. Thus Jessie R., aet. forty- 

* S. Mackenzie found it most frequent after eczema, Brit. Jour. Derm., 
vol. i. (1889), p. 285; analysis of twenty-one cases. 

\Amer. Jour. Cut. Med., vol. iv. (1886), p. 25. 

% In 1804, when mercurial inunction was extensively used, Moriarty of 
Dublin published a brochure with a series of cases which he called 
mercurial lepra, but which were really exfoliative dermatitis. 



PITYRIASIS RUBRA. 397 

seven, came to me with dermatitis extending over almost the 
whole body; there was moderate hyperemia with dry powdery 
scaliness, the limbs were brighter red than the trunk. She re- 
covered in three months from the onset. 

In a typical case the symptoms are redness, gradually in- 
creasing in extent and intensity, of a venous tint on the lower 
limbs, followed by the development of comparatively fine scales 
constantly shed and renewed. The general health is but little 
disturbed at first, but eventually there is increasing weakness, 
marasmus, and death by exhaustion. The skin towards the 
end loses its red color and becomes of a yellowish tint; it 
atrophies and shrinks, this thinning being a marked and diag- 
nostic feature. Jadassohn,* who has written an able and ex- 
haustive paper on Hebra's form, while contending that it is an 
absolutely definite and separate disease, admits that to Hebra's 
description must be added, chiefly on the authority of Kaposi 
and H. Hebra, the following symptoms: The desquamation, in- 
stead of being fine, may be large and free; there may be actual 
thickening and edema of the skin instead of thinning; itching 
maybe a notable feature; slight moisture may be present; ulcer- 
ation may not be absolutely confined to bony points of 
pressure; enlarged lymphatic glands; and, finally, that the prog- 
nosis is not altogether unfavorable. These additional symp- 
toms are the connecting links to the other forms. In W. Peter's 
case f the lymphatic glands were enormous, and the spleen was 
enlarged, but the blood was normal. In Elliot's case * the first 
attack was only an erythrodermia, and he only suspected pity- 
riasis rubra of Hebra. Two years later another attack was 
typical of the disease with enlarged glands; subsequently the 
man died with general tuberculosis. 

Course and Termination. — The course of pityriasis rubra is 
very variable. It is most common for it to come on suddenly, 
become complete in a few days, and then continue for days or 
months, or years perhaps, or only end with life itself. It may 

* " Ueber die Pityriasis rubra." (Hebra), by J. Jadassohn, Arckiv f. 
Der?n., 1892. Full critical abs. by Doyon, Ann. de Derm, et de Syph., 
vol. iii. (1892), p. 413. Loc. tit., vol. lvii. (1901), p. 33. Kopytowski and 
Wielowieski give the pathology and anatomy. 

f Dermat. Zeitschrift, vol. i., part iv. 

%Amer. Jour. Cut. Dzs. t vol. xv. (1899), p. 35. 



398 DISEASES OF THE SKIN. 

take several months to involve the entire surface; or in some 
cases, after having been confined to a few regions for some 
time, it slowly, or without apparent reason, rapidly becomes 
general. Many acute attacks get well in a few weeks or months, 
and even after years they may recover, sometimes spontane- 
ously, and others, apparently, as the result of treatment. The 
disease predisposes to future attacks, some patients having an- 
nual recurrences, others going on for long irregular intervals; 
and even when cases are apparently getting well, a sudden re- 
lapse is not at all infrequent. 

The unfavorable cases may go on to death in a few weeks or 
months with the symptoms already described, or they may drag 
on for many years, and die of gradual exhaustion, or of some 
intercurrent disease. When the case is getting well there is a 
diminution in the intensity of the redness, the scales are less 
quickly reformed, then clear places appear, increase in size, and 
gradually the whole skin resumes its normal appearance, leav- 
ing the patient more sensitive to cold than before, which may 
to some extent explain his liability to future attacks. 

Children. — The disease is very rare in children; and when it 
does occur runs a more acute course, is generally attended with 
severe constitutional symptoms, and is more likely to lead to 
death. The skin lesions have the same characters as in adult 
cases. In most cases it has been preceded by some other form 
of dermatitis. Some of these cases of general exfoliation are 
probably due to congenital syphilis, as in the following case of 
a boy, set. six weeks, who had been ill a fortnight. The whole 
of the body surface, and the oral mucous membrane, were of a 
deep red color, and the whole skin was desquamating freely, 
but not in large flakes, otherwise it looked like pityriasis rubra; 
the eruption began on the buttocks, but there were no other 
signs of congenital syphilis, and the family history was doubt- 
ful. Non-specific treatment was tried for more than a month 
without benefit; it was then put on hyd. c. cret. gr. i three times 
a day, and was well in three weeks. Dr. Kirk White * records 
a case in a child twelve days old, coming on two days after ex- 
posure to carbonic oxid and acid poisoning, but the child got 
well in a fortnight. 

* Amer. Jour. Cut. Dis., vol. xiii. (1895), p. 341. He reports it as a 
case of the Ritter form. 



PITYRIASIS RUBRA. 399 

Under the name of Dermatitis Exfoliativa Neonatorum,* 
Ritter has described an eruption which he observed in the 
Foundling Asylum at Prague, where nearly three hundred cases 
occurred in ten years. It begins in the first or second week 
of life, and occasionally as late as the fifth, usually in the lower 
part of the face first, but it may begin anywhere with patchy or 
diffuse, soon becoming universal, redness and scaling, which 
may be branny or in laminae, like pityriasis rubra, and either dry 
or with effusion beneath the epidermis; sometimes it presents 
vesicles or flaccid bullae like pemphigus foliaceus, and then 
there are crusts as well as scales, with rhagades on the mouth, 
anus, etc.; there is a total absence of fever or other general 
symptoms. About fifty per cent, die of marasmus and loss of 
heat, with or without diarrhea; in those who recover the skin 
becomes pale and the desquamation gradually ceases, the dis- 
ease running its course in a week or ten days. Mild relapses 
sometimes occur, or there may be septic sequelae-boils, ab- 
scesses, or even gangrene. Ritter regarded it as of septic 
origin; Behrend thought it was pemphigus foliaceus; while 
Kaposi, who had also seen cases in lying-in and foundling hos- 
pitals, while admitting its clinical resemblance to pemphigus 
foliaceus, regarded it as an aggravation of the physiological 
exfoliation of the new-born. Riehl found a long thin mycelial 
fungus, which he thought to be pathogenic, but a schizomycetic 
toxin is a more probable cause. 

Cases have also been described by Billard, von Baer, Caspary, 
and others, .but none have been recorded in this country, f 
Morton of New York and Das of Calcutta have also reported 
cases in 1895 and 1899 respectively, and Spencer reported an 
outbreak in a lying-in hospital in Sydney which he regarded as 
a separate disease, and called it after his own name; but while 
the initial lesion varied as erythema, macule, papule, vesicle, 
pustule, or bulla, it developed into widespread exfoliation, and 
behaved generally like Ritter's disease. 

Etiology. Age. — There appears to be no limit for pityriasis 
rubra at either end of the scale as regards age. I have seen 
one well-marked primary case in a child of two months, and 

* Viertelj. f. Derm. u. Syfih., Heft i., 1879. 

•f-G. Elliot of New York reports two cases with general review of the 
subject in Amer. Jour, of the Med. Sciences, January, 1888. 



4 oo DISEASES OF THE SKIN. 

one of nearly eighty years with recovery; but the majority occur 
between forty and sixty years of age. However young 
the patient may be, it is very unlikely to be of congenital 
origin.* 

Sex. — Both sexes are liable, but there is a decided prepon- 
derance among males, in the proportion of three to two, or 
even higher. The only other predisposing causes known are 
various forms of extensive dermatitis, such as eczema, 
psoriasis, lichen acuminatus or dermatitis due to mercury, 
chrysarobin, arnica, etc. I have shown in a paper read at the 
Paris Dermatological Congress of 1889, \ that there is a close 
relationship between rheumatism, especially the acute form, 
and gout and P. rubra, eleven out of eighteen cases having had 
this association; and Jadassohn points out the frequency of 
tuberculosis in some form, in the Hebra type of cases. Out of 
eighteen cases, in eight tuberculosis could be proved, in one or 
two more it was doubtful, and in the rest no inquiry had been 
made as to the point. 

Of exciting causes, sudden chills have so immediately pre- 
ceded the onset in some cases that they may fairly be inferred 
to have excited the attack. An alcoholic debauch is recorded 
in two cases. Both the exciting and predisposing causes, how- 
ever, leave a large number of cases wholly unaccounted for; 
and since the conditions mentioned, both as exciting and pre- 
disposing causes, are of common occurrence, while pityriasis 
rubra is very rare, there must be some underlying factor at 
which we cannot even guess with our present knowledge. 

Pathology. — Histological examination shows that the disease 
is a dermatitis, quite superficial at first, but when it has lasted 
some time the whole depth of the skin is involved, and eventu- 
ally new connective tissue is developed, which subsequently 
undergoes cicatricial-like contraction, with abundant pigmen- 

* Rasch describes the case of a woman, aet. thirty-two, who had suffered 
from universal redness and exfoliation from birth; a brother and sister 
had suffered in the same way, but had died at three and a half and nine 
years respectively. Histologically the changes were those of ichthyosis, 
and he called it therefore "ichthyosis rubra." Derm. Zeitsck., vol. viii. 
p. 669. Abs. Brit. Jour. Derin., vol. xiv. (1902), p. no. Sangster had a 
somewhat similar case, but the ground color was normal; he called it 
" congenital exfoliation of the skin." 

\ Transactions, 1890, p. 68. 



PITYRIASIS RUBRA. 401 

tation, hyperplasia of the elastic fiber bundles, and obliteration 
of the skin appendages. 

The anatomy, however, throws no light upon the original 
pathological factor; whether, as Pye-Smith thinks, it is a pri- 
mary dermatitis, or, as many think, it is consequent on some 
defect in the nervous system, there are too few facts to allow of 
anything more than conjecture. Assuming that it is of nerv- 
ous origin, it has still to be determined whether it is of periph- 
eral or of central origin. If central, however, the disease 
must be placed high up in connection with the trophic centers. 

Myelitis, with a P. rubra condition of the skin, has been re- 
corded by Jamieson, and it is of value as evidence in this direc- 
tion. Quinquaud and Lancereaux also describe both periph- 
eral and central nerve changes of inflammatory character, in 
connection with the disease. On the other hand, the spinal 
cord, pons, and medulla in two of my cases were carefully ex- 
amined by Dr. Frederick Mott, and no marked changes could 
be made out. In the light of recent pathology it is probable 
that the nervous system is only indirectly at fault, the primary 
cause being a bacillus or its toxin acting on the nervous sys- 
tem. Haushalter found a microbe with white culture resem- 
bling, but different from, staphylococcus albus, but its patho- 
genic character was not proved. It is also open to discussion 
as to whether the toxin is formed in the skin or from within 
the body; in either case it would appear that it is an auto-toxin 
which the patient manufactures to his own detriment for an 
indefinite period. 

Anatomy. — Skin removed from the dead body has been examined by- 
several investigators. As I believe I was the first to examine skin from 
the living body, where the disease had existed only two weeks, I will give 
the results. 

The skin was taken from the left side of the trunk. The process was 
entirely confined to the part of the skin above the longitudinal vessels of 
the superficial plexus, with comparatively little change in the lower half 
of this part. The sweat glands and other structures below the plexus 
were, therefore, quite normal. 

In the horny layer the upper two-thirds were split off from the lower 
third, which was closely adherent to the rete; the individual layers were 
not at all separated from each other, as in psoriasis (see Fig. 23). The 
rete was decidedly thinned over the papillse, sent down long narrow 
processes between the papillse, and thus produced a great apparent 
enlargement of them. The individual cells of the rete were unaltered, 
26 



402 



DISEASES OF THE SKIN. 



and no leukocytes were observed among them. The papillae were 
enlarged transversely, as well as longitudinally; both they and the 
immediately subjacent corium were infiltrated with leukocytes, but only 
in moderate numbers, and below this they became quite sparse; there 
were none below the superficial horizontal vessels. The fibers of the 
papillae and upper part of the corium were separated and stretched, 
inferably by effusion of serum. The cell infiltration was most abundant 
round the papillary vessels and the sweat ducts, where they traversed 




Fig. 23.— Pityriasis rubra, two weeks' duration, side of trunk. 

scales; d, rete, thinned above, but with enormously elongated inter- 
papillary processes; e, papilla enlarged vertically and transversely; 
b, papillae and upper part of corium infiltrated with leukocytes (the 
infiltration was much more abundant than is depicted in the wood- 
cut); c, dilated blood-vessels. 



the affected part of the corium; the lumen, however, was unobstructed 
here, but occluded in the rete. 

In Hans Hebra's case of his father's type, of thirteen months' duration, 
the cell infiltration was present throughout the corium, and very abun- 
dant round the appendages of the skin, being present between the acini 
of the sweat glands. In a case of five years' standing there were leuko- 
cytes even in the fat, but " the general impression given was that of a 
scar with epidermis over it " 

The papillae, sweat and sebaceous glands were atrophied or absent. 
There were large coils of elastic tissue, and yellow pigment infiltrated the 
lowest part of the rete and was scattered in masses throughout the corium. 



PITYRIASIS RUBRA. 403 

Jadassohn found in Hebra's form slight infiltration of round cells in 
foci in the upper portion of the corium; increase of the connective tissue 
nuclei; large numbers of giant cells, especially in the papillary body and 
round the sweat glands; great accumulation of yellow and brown pigment 
in the corium; extreme proliferation of the cells of the rete and invasion 
of immigrant cells; thinning of the stratum granulosum and raising up 
of the horny layer into lamellae. 

Petrini and Babes found degeneration of the collagen substance of 
the papillae and vessel walls and thrombi in the vessels. Jordansky 
analyzed the scales and found the nitrogen in them was about normal 
(fifteen per cent.). The patient shed from 4 to 8 grams of scales a 
day, averaging 5^. See Unna's " Histopathology," p. 271, for further 
details on the Hebra type, and pp. 274-276 for histology of the other 
forms. 

Diagnosis. — Its sudden onset and rapid involvement of the 
entire surface; the intense redness, without exudation of fluid 
or thickening; the copious exfoliation of thin, papery scales; 
and the tendency, if untreated, to become chronic and lead to 
a fatal issue, are its most characteristic features. 

It may have to be distinguished from psoriasis, eczema, pem- 
phigus foliaceus, and lichen acuminatus. 

It differs from psoriasis in its being absolutely universal, 
which psoriasis * never is in my experience; the rapidity with 
which it spreads over the body; the absence of thickening, and 
the scales never adhering to each other in silvery crusts; the 
scales being large, thin, papery, and easily detachable; and the 
absence of red puncta when the scales are detached. Some of 
the more highly inflamed cases of psoriasis approach the pity- 
riasis rubra type more closely than has just been described, but 
they are not universal, and retain many of the psoriasis char- 
acters. 

It differs from eczema in the first four particulars. It is never 
in yellow crusts; there is seldom exudation, or, if present, it is 
usually scanty and partial; but, if abundant, does not stain, and 
seldom stiffens, linen; and itching is absent, or at least moder- 
ate. Neither in eczema nor psoriasis are the general symptoms 
so severe. 

It presents many points of resemblance to pemphigus folia- 
ecus, but it differs from it in that there are no flaccid bullae, with 

* Universal psoriasis of some authors is applied to cases of pityriasis 
rubra which have developed from psoriasis. I have never seen a case of 
psoriasis retain its characters and yet be absolutely universal. 



4 o 4 DISEASES OF THE SKIN. 

their attendant disagreeably smelling discharge; and it is, as a 
rule, more amenable to treatment. Pemphigus foliaceus is 
most common in women, P. rubra in men. It must be borne 
in mind that the bullae in pemphigus foliaceus rupture so quickly 
that they are easily overlooked, and that in rare instances pem- 
phigus foliaceus has developed on a pityriasis rubra. 

It differs from lichen acuminatus, which also is rarely uni- 
versal, in its rapid spread, the absence of thickening, the abun- 
dance and character of its scales, the total absence of papules, 
its being less influenced by arsenic, and its not beginning with 
the characteristic papules of lichen acuminatus. 

The large and small scale types can be distinguished from the 
cases of general desquamation following erythematous or other 
eruptions, since, when the scales are once thrown off, there is 
no renewal of them. 

Prognosis. — This is always serious, as it is impossible to pre- 
dict what course the disease will take, and even when it appears 
to be doing well sudden relapses may upset previous calcula- 
tions; still, instead of being uniformly fatal, as at first believed, 
about half the recorded cases have recovered, some of them 
from several attacks. Personally, I should say that this mor- 
tality is far too high even for universal cases. The partial at- 
tacks are, of course, more favorable, but are liable to become 
universal at any time. The disease is more fatal in children 
than in adults, and runs a quicker course for ^ood or ill. 

In the Hebra type the prognosis is bad as a rule, but it is not 
so uniformly fatal as Hebra himself thought it. 

Treatment. — This must be both external and internal. Ex- 
ternal treatment is of great use both in relieving discomfort and 
diminishing the congestion. Oily applications are usually the 
best; I have seen very good results from wrapping the patient 
up in bandages soaked in linimentum calaminas, and also from 
spreading a thick layer of Lassar's paste, omitting the salicylic 
acid, over the body, and covering with butter cloth. The 
lactate of lead liniment and the glycerin of the subacetate of 
lead have also proved useful (F. Lin. 2, Lot. 39 and 40) ; but if 
employed great care must be exercised to prevent the patient 
getting chilled during their application and removal. 

Internally. — After correcting, if present, any errors of the di- 
gestive system, quinine in full doses is the best treatment in 



PITYRIASIS ROSEA. 405 

acute febrile cases. In chronic cases arsenic is strongly recom- 
mended, but it often fails conspicuously, and is, I believe, very 
unreliable. When the patient is losing flesh, cod-liver oil, 
iron, and a highly nutritious but easily assimilable diet, and 
sometimes the liberal use of stimulants, are required. Diu- 
retics are strongly recommended by Dr. Tilbury Fox. The 
course that I have found very successful is as follows : The 
whole of the body is enveloped in bandages soaked in calamin 
liniment, which should be slightly warmed in cold weather; the 
bowels are cleared out if necessary, and then pot. bicarb, gr. 20 
is taken every four hours, with acidi citrici gr. 12, and quinae 
sulph. gr. 3 to gr. 5 during effervescence. The patient is fed 
up as much as possible, but stimulants are withheld, as a rule, 
unless there are signs of vital depression. In all cases rest in 
bed is absolutely enjoined, and they should be uncovered as 
little as possible, as they are extremely sensitive to the slightest 
chill. I consider it highly dangerous for patients with even 
partial attacks to go about, and indeed treatment is generally 
unsuccessful until the patient lies up. 

Improvement very often does not set in for some weeks, but 
the treatment should not be changed too hastily on that ac- 
count, and the mind of the patient should be encouraged to be- 
lieve that everything possible is being done. 

Arsenic may be given towards the end of the attack, if some 
part of the eruption is slower in going away than the rest, and 
in cases of long duration; but I never find it advantageous in 
the earlier stages and very rarely give it at all. 

PITYRIASIS ROSEA.* 

Synonyms. — Pityriasis maculata et circinata: Herpes tonsurans 
maculosus (Hebra). 

Definition . — An acute, widely spread exanthematic eruption 
characterized by pale red, slightly scaly patches or circles. 

This is one of the less common eruptions, occurring about 
once in 250 cases in my experience. It was first described by 

* Literature.— Author's Atlas, Plate XXX. Owing to the delicate 
characters of the eruption, it is not possible to represent it quite 
satisfactorily. 



4 o6 DISEASES OF THE SKIN. 

Gibert,* and subsequently by Bazin, Hardy, Horand, and 
other French writers, f and more recently by Duhring % and 
Behrend.§ 

Symptoms. — Slight febrile and other symptoms of general 
disturbance occasionally precede and accompany an acute wide- 
spread outbreak of the eruption, and generally there is slight 
enlargement of the post-sterno-mastoid and submaxillary 
glands, and in one of my cases of two months' duration the 
axillary and inguinal glands. Sometimes there is also conges- 
tion of the fauces, but in a slowly developing eruption of limited 
extent general symptoms would be absent. Gilchrist observed 
in the urine a high sp. gr. and urates in several cases, probably 
of the febrile type. 

As Brocq states, a single primitive patch, usually situated 
somewhere on the trunk, precedes the general outbreak for a 
week or ten days in most and probably all cases, though it is not 
always traceable. Its larger size, and being sometimes the only 
circinate patch, may indicate it in some cases. The eruption 
varies in its extent, sometimes being confined to one or two 
regions, but is generally extensive, and it may be nearly uni- 
versal. It commonly commences upon the abdomen, but may 
begin on the upper part of the chest, the side of the neck, and 
occasionally on the face or arm. Thence it spreads with a 
varying extent and rapidity over a large area, which may in- 
clude the whole trunk, neck, and limbs in from two to three 
weeks, but is thickest on the abdomen and buttocks, and is 
usually absent or sparse below the elbows and knees, and on 
the face. 

The eruption is scarcely raised above the surface of the 
healthy skin, and occurs in two forms, the maculate and the 
circinate. 

P. maculata is in small, roundish, oval, or irregular, pale red 
patches, with ill-defined borders, varying in size from a mere dot 

* Gibert, " Traite pratique des maladies de la peau " (Paris, i860), p. 
402. 

fVidal, Ann. de Derm, et de Syph., January, 1882, and the other 
French writers alluded to. 

% Duhring, American Journal of the Medical Sciences, October, 1880, 

P- 359- 

§Behrend, Berlin klin. Wockensckrift, 1881, No. 38; also Colcott Fox, 

La?icet, September 20, 1884. 



PITYRIASIS ROSEA. 407 

up to about three-quarters of an inch in diameter, and thinly 
covered with very fine scales. This is the form originally de- 
scribed as P. rosea by Gibert. 

P. circinata is in oval or roundish patches, with well-defined 
borders, which, as the patch increases peripherally, soon be- 
come more prominent than the center, and the whole is at first 
finely scaly, and also pale red; but after attaining about half an 
inch in diameter the center begins to clear, and the larger 
patches are converted into rings, with pale red, scaly borders, 
and small fawn-colored centers; still continuing to enlarge, but 
rarely to more than an inch, the ring is broken and ultimately 
clears away, leaving only the pale fawn-colored stain. The 
separate patches may coalesce more or less with their neigh- 
bors, and thus irregular gyrate areas of considerable extent be 
formed. The individual patches vary in size, depth of redness, 
and amount of scaliness. Interspersed among the large 
patches are small spots from about the area of a measles papule 
upwards, and these enlarge peripherally to form the larger 
lesions. The gradation of the development of the whole 
process may be thus traced simultaneously, and the eruption 
may be disappearing on the trunk and still well out on the 
limbs. The eruption may be so abundant as at first to re- 
semble an exanthem; in the most acute cases the initial papular 
elements are very abundant. There may be some attempt at 
arangement in the patches being in parallel sloping lines from 
the center to the periphery, determined probably by the lines of 
fissure or the blood-vessels. There is itching at night, or 
whenever the patient becomes warm, usually only of moderate 
intensity, but occasionally severe. 

The eruption gets well spontaneously, in from two weeks to 
two months, as a rule, but Vidal had a case which lasted six 
months, and I have had one even longer, and several of three 
or four months. Some of these long-standing cases have been 
kept going by the eruption having attacked one region at a 
time, and as that ran its course, another region was involved. 

Variations. — A variation which materially alters the general 
aspect is when the papular elements for the most part remain 
small throughout their whole course, only a few patches or 
rings being interspersed. The patches also sometimes project, 
and are more red and scaly than usual. Hallopeau has ob- 



4 o8 DISEASES OF THE SKIN. 

served it limited to the lower extremities, and also that some- 
times the patches project like wheals; in one of these cases of 
Hallopeau, the primary plaque was on the thigh two months 
before generalization. 

Etiology. — One-third of the cases are in children, but it may 
occur at all ages, the extremes in my practice being seven 
months and seventy years. Sex, position, and season do not 
seem to have any effect. In short, we are perfectly ignorant of 
its etiology. Bazin regards it as arthritic. Jacquet states that 
dilatation of the stomach is a specially common concomitant, 
and Besnier seems to agree with him, but this could scarcely 
have any etiological significance. Twice I have seen it in two 
members of the same family, and Peroni records an epidemic of 
it, but it is not generally considered to be contagious. 

Kromayer records a case of its occurrence on and limitation 
to the legs after putting on new stockings, but this was prob- 
ably only an irritant (arsenical?) rash imitating pityriasis rosea. 

Pathology. — Vidal ascribes it to a minute fungus, which he 
calls " microsporon anomceon"; but his description accords 
more with a micrococcus than a fungus, and micrococci are so 
generally present in scales that we must pause before we ac- 
cept it as the fons ct origo malt, unless the disease can be repro- 
duced from a cultivation of the organism. 

Its generalization a week or ten days after the appearance of 
a primitive patch is suggestive of an invasion of a microbe from 
without, followed by its multiplication and absorption into the 
blood stream and general distribution. 

Anatomy. — According to Unna* in the early stage there is a parakera- 
tosis and loss of the granular layer with diminished renewal of the 
epithelium by new-formed prickle cells, as compared to a psoriasis. 
There is marked dilatation of the vessels of the superficial plexus with 
edema, and an abundance of new connective tissue cells, with two or 
three nuclei, beyond what the clinical appearances suggest. The leuko- 
cytes are sparse, but there are some plasma and mast-cells. All these 
changes are accentuated in a more advanced lesion; there are even 
microscopic vesicles, and he compares the process to that of flat papular 
seborrheic eczema, but with more edema and spindle cell multiplication, 
and no micrococci or other recognizable microbe in the scales. 

Blaschko f considers that the most characteristic feature is an aggluti- 
nation of cells in the stratum lucidum and stratum corneum, in which 

*" Histopathology," p. 268. \ Annates, vol. x. (1899), p. 1250. 



PITYRIASIS ROSEA. 409 

there may be from three to five cells fused together with a common 
nucleus. There is mitosis even on the horny layer as well as the upper 
rete layers. The process begins in the derma and in the rete, the para- 
keratosis comes later. No micro-organisms were discovered. Meyer 
examined four cases and agreed generally with Blaschko, but he had 
found in one case in a lymphatic lacuna a series of cocci in columns, and 
also in the infundibula of the glands. In three cases he had found 
spores like Unna's flask bacilli. 

Hollmann,* who has examined lesions at different stages, found very 
different appearances, according to the stage. The process begins in the 
derma with marked vascular dilatation of the superficial plexus and peri- 
vascular cell infiltration in the upper part of the corium, the epidermic 
changes being slight at this stage, but subsequently the epidermis under- 
goes the spongioid transformation of the epithelium, similar to that 
found in moist forms of eczema by Unna. 

Diagnosis. — The pale red tint, the slight scaliness and eleva- 
tion, the widely spread distribution, the occurrence in flat 
papules, patches, or circles, and the tendency to spontaneous 
involution, make up the distinctive features of the disease. 
Vidal considers P. rosea is a separate disease from P. maculata 
and circinata, the former running a more definite course, the 
latter alone possessing the special organism; in this respect few 
agree with him, most authors regarding them as identical dis- 
eases, and attaching a secondary importance to the organism. 

From early squamous and circulate syphilids, which it most re- 
sembles, besides the staining and concomitant symptoms of 
syphilis, the scaling and infiltration are much greater in the 
syphilid, and the eruption is of slower development and course. 
The presence, in some cases of P. rosea, of enlarged glands and 
congested fauces requires care and the consideration of all the 
symptoms taken together to avoid mistakes. 

The circinate patches are somewhat like psoriasis, but much 
less elevated, much less scaly, lacking the hyperemic papillae, 
and usually not at all conspicuous in the usual psoriasis posi- 
tions. The circinate form may be very like seborrhea papulosa, 
but this eruption is almost limited to the middle of the chest 
and back, and is never on the limbs, has a papular border, and 
is primarily papular; moreover, it will last for years if un- 
treated, while P. circinata gets well in a few months at the most, 
and usually in a few weeks. The large number of patches and 

* " Histopathology of Pityriasis Rosea." Hollmann, Arch.f. Derm. u. 
Syph., vol. li. (1900), p. 229. Abs. in Annates, vol. i. (1900), p. 1103. 



4 io DISEASES OF THE SKIN. 

.extent of distribution, the rapid development, and the absence 
of the trichophyton fungus distinguished it from tinea circinata, 
with which it was confused, even by Hebra. 

Prognosis. — This is always favorable, the disease getting well 
spontaneously in all but a very few cases, and even in those is 
amenable to treatment. 

Treatment. — Whilst most cases get well spontaneously, others 
do not, and no patient would be satisfied with inaction for sev- 
eral weeks, especially as itching is sometimes a marked symp- 
tom. Salicin internally has certainly influenced involution in 
my hands, fifteen grains three times a day having produced an 
immediate effect on a rash which had persisted for several 
weeks and in one case for months. 

To allay the irritation the surface may be sponged with a 
lotion of liq. carb. deterg. and liq. plumbi subacet. aa 3iss to aq. 
rosae §viij ; or calamin lotion with TTLx liq. carb. detergentis may 
be painted on with a shaving brush and allowed to dry. Spong- 
ing first with a watery solution of hyposulphite of soda 5ij to 
gviij, and directly after with a solution of tartaric 5i to ^vn], i. e., 
the nascent sulphur treatment, has appeared to be of great 
service in my hands. S. Mackenzie advocates boric ointment. 

Weak Harrogate sulphur baths would be of service if they 
were easilv accessible. 



EPIDEMIC EXFOLIATIVE DERMATITIS.* 

Synonym. — Epidemic eczema; Epidemic skin disease. 

In the autumn of 1891, chiefly in July and August, a remarka- 
ble epidemic eruption made its appearance in the Paddington 
(163 cases), the St. Marylebone (193), and the Lambeth (25) 
Poor Law Infirmaries. In the Hanwell Lunatic Asylum also, 

* Literature. — A well-illustrated monograph by Savill, 1892; and in 
Brit. Jour. Der?n., vol. iv. , 1892, in the February, March, and April 
numbers. There were also many communications on the subject in the 
Lancet and Brit. Med. Jour., in vol. ii., 1891, vol. i., 1892, and vol. ii., 
1894, including another article by Savill and a comprehensive leader in 
the Lancet of September 29. Also Clinical Journal, October 30, 1894, a 
Clinical Lecture by Dr. Lees. "On Histology," Echeverria. Brit. 
Jour. Derm., vol. vii. (1895), p. 9; and Motiatsh. f. Derm., vol. xx. 
Savill, " Nouvelle Iconographie de la Salpetriere." 



EPIDEMIC EXFOLIATIVE DERMATITIS. 41 1 

there were 38, in St. Mary's Hospital 4, and a few other isolated 
cases. A similar outbreak occurred in the Greenock Parochial 
Asylum in 1888. 

Smaller outbreaks have occurred since, especially in 1893 in 
the Paddington and Fulham Infirmaries and in the Bethnal 
Green Workhouse (86) and the City of London Infirmary. 
There have also been sporadic cases. A curious group oc- 
curred at Loughton, in a family living in a cottage on a hill, 
under Dr. Butler Harris, who sent the most severe case to me 
for diagnosis. The father, mother, and children were attacked. 
The one I saw was a boy, set. eleven, who had several relapses. 
Careful investigation showed that they got their milk from a 
cow which was watered at a pond contaminated by a neighbor- 
ing cesspool. The milk supply was suspected at several of the 
infirmaries, and although some evidence was obtained favor- 
able to this theory of origin, it fell very far short of being con- 
clusive, and in one institution the disease continued to spread 
after the milk supply was stopped. 

The disease occurred in two main types — a moist one, re- 
sembling eczema, and a dry one, indistinguishable from pityria- 
sis rubra. Dr. Savill gave an elaborate account of the disease 
from the 163 cases under his care at the Paddington Infirmary; 
and, thanks to him and Dr. Lunn, I was able to examine a large 
number of cases both at Paddington and St. Marylebone. Al- 
though in two-thirds of Dr. Savill's cases there was more or 
less discharge, there was always free exfoliation of the epider- 
mis, and many were typical examples of pityriasis rubra, as far 
as appearances are concerned, and there was a heavy mortality 
among the old people. A few of the attendants on the sick, a 
few children and young people, were attacked; but the great 
majority were middle-aged or old persons of both sexes, in the 
infirmaries for other diseases. As a rule the eruption was not 
preceded by any noticeable signs or symptoms, and there was 
no fever, except towards the end in severe and fatal cases. 
Among antecedent or concomitant symptoms anorexia was 
common; some had vomiting, some diarrhea, some both; and 
a few had sore throat. In nearly all whom I personally exam- 
ined, except the very aged, the occipital glands and those down 
the neck were enlarged and sometimes tender, and occasion- 
ally the submaxillary glands were also enlarged. This enlarge- 



412 DISEASES OF THE SKIN. 

ment could not be accounted for by the eruption in the head, as 
it occurred in some cases where the head was almost free. The 
parts most frequently first attacked were some portion of the 
upper limb, the face, and scalp, fifty-seven per cent, commenc- 
ing in one or other of those parts, the exposed positions in fact; 
in only seventeen per cent, were the lower limbs first attacked, 
and the rest began in various positions. The first symptom 
was a sensation of itching, then numerous acuminate red 
papules appeared, irregularly grouped, and seated at the fol- 
licles. These either remained unchanged for a time, or some 
of them coalesced into red patches, and the eruption spread 
over the body, sometimes slowly, sometimes rapidly, until the 
whole surface was affected without any interval, with a deep 
red infiltration, covered with abundant flaky scales;- and thus, 
but for the history, a typical pityriasis rubra was presented. 
About half were thus universal. In many vesicles formed on the 
papules on the second or third day, and discharged, producing 
a moist eczematous surface. A less frequent mode of com- 
mencement was the formation of round, well-defined, erythe- 
matous patches. In six of Savill's cases small flat papules ap- 
peared, which enlarged peripherally and formed a circular red 
ring, inclosing a depressed area covered with minute vesicles. 
While the majority were symmetrical from the first, in some 
a local origin could be traced, and then after some days there' 
was generalization. A few of these of local origin were aborted 
by painting with collodion or iodin. 

The orbits were often much affected, and then conjunctivitis 
was usually present. The disease in the universal cases usually 
ran its course in from six to eight weeks, but many had re- 
lapses, and a few had actual second attacks. In those who re- 
covered there was very deep pigmentation of the skin, and all 
the nails and hair were shed in the severe cases, in one case 
even where no rash was observed on the scalp. In the fatal 
cases — thirteen per cent, in the Paddington, and five per cent, 
in Marylebone Infirmary — death was usually by exhaustion, 
preceded by subsultus tendinum, shallow respiration, and coma. 
Some had complications, such as pneumonia, gangrene of the 
feet, etc.; albuminuria was present when there was a large area 
of skin involved. No cause, after the most diligent search, 
could be assigned for the outbreak; but from the scales and 



CHEILITIS EXFOLIATIVA. 413 

fluid from unruptured vesicles both Savill and Risien Russell 
isolated an organism very like staphylococcus pyogenes albus, 
but, unlike the latter, they were diplococci in rod-like segments, 
did not liquefy gelatin, and had not the specific effect on animals 
that staphylococcus albus has. Risien Russell could find no 
such organism in the blood of an ordinary pityriasis rubra case. 
Echeverria claims that there are some very special changes in 
the nuclei of the prickle cells. Treatment had little effect in 
shortening the course of the disease, but for the severe cases 
treatment on the same lines as that for pityriasis rubra would 
be most helpful. 

CHEILITIS EXFOLIATIVA.* 

Deriv. — #«zAo?, the lip. 

Synonyms. — Exfoliative inflammation of the lips; Psoriasis 
labialis (Bateman); Pityriasis des levres (Raver); Eczema 
exfoliant des levres (Besnier-Doyon). 

Although this rare affection was known to Bateman and 
Raver, and was fully and accurately described by the latter, it 
has only gained attention of late years from the writings of 
Besnier and the other writers mentioned in the footnote. It is 
a rare and very rebellious disease, quite distinct from ordinary 
eczema of the lips, but according to Besnier is closely asso- 
ciated with seborrhea of the face and scalp. 

It affects primarily and chiefly the lower lip, but the upper 
may be secondarily involved in a minor degree. It is confined 
for the most part to the red of the lips, but I have seen it ex- 
tending slightly inwards on the mucous membrane, while the 
extreme outer border was free. The lip is always swollen and 
covered with a dry yellowish or brownish crust, which may be 
thin and flaky or up to half an inch thick (Galloway). Beneath 
the crust the lip is dry, glazed, and cracking, sometimes granu- 

* Literature.— Kaposi Besnier-Doyon's edition, vol. i. (1891), p. 664, 
note, with references. Unna. Balby's case, Monatsh. f. prak. Derm., 
vol. xi. p. 317. Galloway, Brit. Jour. Derm., vol. vii. (1895), p. 113. 
Jamieson, Brit. Med. Jour., December 7, 1895, with colored plate. 
Stelwagon — "Persistent Exfoliation of the Lips," two cases, Amer. 
Jour. Cut. and Gen.-Ur. Dis., vol. xviii. (1900), p. 268. 



4 i4 DISEASES OF THE SKIN. 

lar and bleeding, but seldom oozing. The intensity of the in- 
flammation and consequent crusting varies considerably, the 
ameliorations leading to fallacious hopes of cure always 
doomed to disappointment, so far no case having been really 
cured. Galloway's case lasted fifteen years. Besnier always 
found it in association with seborrhea of the face and scalp, 
and it was so also in Galloway's and Stelwagon's cases. In 
Jamieson's case seborrhea was absent, and in my own was not 
present on the face, and I have no note about the scalp. Still 
it is evidently an important factor. In my own case, a man 
aet. twenty-seven, the lip was irritable for a year, and much 
picked, therefore, before the disease began. Dyspepsia has 
also been present in a large proportion; age and sex are not 
important factors. 

Pathology. — This is unknown. Stelwagon found various 
microbes, but was unable to isolate the pathogenic one. Leith 
examined Jamieson's case, and found such marked thickening 
of the prickle cell layer as to suggest to him a mild form 
of epithelioma, but the appearances were quite consistent 
with those of chronic inflammation, which is much more prob- 
able. 

Treatment. — This has been most unsatisfactory, temporary 
amelioration only having been obtained. Stelwagon painted 
on lactic acid, at first diluted, and then full strength every six 
hours for four applications, and repeated it in ten days, using 
an ointment of ichthyol and acetanilid. Under this treat- 
ment the lips kept healed for five weeks, when the report was 
made. Jamieson also had previously used lactic acid with bene- 
fit, following it with salicylic wool, fastened on with flexile 
collodion. Besnier got the lips smoother with borax and rha- 
tany, and then covered them with traumaticin. Any digestive 
troubles and seborrhea should be most carefully attended to. 

LICHEN. 

Deriv. — \eixvv, a lichen. 

The term lichen was applied by Willan and his followers to a 
heterogeneous collection of diseases, to some of which it still 
clings, with the single property in common that papules are the 



LICHEN. 415 

conspicuous feature in some part of their course. The lichen 
class is now restricted, as Hebra proposed, to those diseases in 
which inflammatory papules, undergoing no metamorphosis 
during their whole course, constitute the main feature of the 
disease. Under this definition come: 

L. planus (Wilson). 

L. variegatus. 

L. ruber acuminatus (Kaposi) seu Pityriasis rubra pilaris 
(Devergie). 

L. scrofulosus. 

L. pilaris seu spinulosus. 
Before describing this group it is desirable to state briefly 
what it does not include, as much confusion is produced by the 
loose way in which the term has been, and is still applied, by 
those who have not paid special attention to the subject. Each 
affection is fully described in its proper place. 

Acute L. Simplex is still regarded by some authors as a defi- 
nite disease. It is a follicular hyperemia, and may involve the 
hair, sebaceous, or sweat follicles. Chronic L. simplex (Vidal) 
is regarded by most French authors as a separate disease, but 
Besnier does not accept it, nor can I. It is the lichen circum- 
scripta of old authors, and Brocq and Jacquet describe it as a 
chronic circumscribed neurodermite, on the theory that it is a 
special reaction of the skin to scratching, constituting what 
they call primary lichenification, itching without eruption being 
the first symptom. The lesions are circumscribed patches 
chiefly occurring about the neck or groin. Many of these cases 
are really lichen planus, and in not a few cases, after remaining 
as a single thickened patch for weeks, months, or years, other 
lesions of lichen planus arise elsewhere. Some cases are the 
remains of a chronic squamous and probably seborrheic 
eczema. L. agrius is an obsolete term for an acute follicular 
eczema. 

L. Urticatus is the urticaria of children, in which the wheals 
are succeeded by inflammatory papules, and in some cases the 
wheals themselves are not larger than papules. L. pilaris 
is often used instead of keratosis pilaris. Inflammatory 
L. pilaris is the equivalent of Devergie's lichen spinulosus. 



4 i6 DISEASES OF THE SKIN. 

L. lividus is hemorrhage into the hair follicle or follicular 
purpura. L. tropicus, or prickly heat, is an inflammation of 
the sweat apparatus, and is therefore a form of miliaria. 
L. strophulosus, " red gum," is also a sweat rash, or miliaria 
of young infants. L. syphiliticus is applied to two forms of 
papular syphilids, in which the lesion is at the hair follicle. 

L. Circinatus is one of the forms of seborrheic dermatitis of 
the body. Seborrhea papulosa. 

Lichcnification. — This term has come into use recently through 
the advocacy of Brocq and Jacquet. It is applied to the thick- 
ening of the skin, which is not uncommon in chronic dry in- 
flammations, e. g., eczema, lichen planus, pityriasis rubra, etc., 
attended with itching and consequent scratching, whereby the 
natural lines of the skin are deepened and the patch, whether 
circumscribed or diffuse, is quadrilated, or broken up into 
squares, bounded by these deepened natural lines. Brocq 
classifies these thickenings into primary and secondary, diffuse 
and circumscribed, but these seem to me to be unnecessary 
complications of what is otherwise a useful term for a certain 
kind of thickening of the skin. 



LICHEN ACUMINATUS.* 

Synonyms. — Lichen ruber (Hebra); Pityriasis rubra pilaris 
(Devergie); Lichen ruber acuminatus (Kaposi). 

Definition. — A primarily non-inflammatory (?) disease charac- 
terized by follicular, conical, or round papules with horny 
centers, tending to become general or even universal in distri- 
bution. 

The first clearly described case was that communicated by an 
Englishman, Claudius Tarral, to his former master, Rayer, 
from a case in St. Bartholomew's Hospital in 1828. 

* Literature. — Colored illustrations under the above synonyms are 
published in Barensprung's and Hebra's Atlas; see footnote, p. 418. 
Hebra's large Atlas, Plate II., Lief, iii., is not a good example. Neu- 
mann's Atlas, Plate XLI., copied by Morrow, Plate LVIII.; also 
Monograph, Archiv f. Derm. u. Syph., vol. xxiv. (1892), p. 3, very good. 



LICHEN ACUMINATUS 417 

Hebra, in the first edition of his work, described the disease 
under the name of lichen ruber, but subsequently mixed up 
other diseases with it. Devergie described it independently 
under the title of pityriasis rubra pilaire; this name is still re- 
tained by French authors, of whom Richaud, Besnier, and 
Brocq may be especially mentioned, who have added much to 
our knowledge of the disease. 

Kaposi again, under lichen ruber acuminatus, has introduced 
a further complication of the subject, and in the last twelve 
years a great controversy has arisen as to whether the three 
descriptions related to one or to separate affections. Owing to 
the paucity of cases recognized in England up to about 1890, 
English writers have been content to watch the fray and record 
the points made by the several adversaries; but in America 
Taylor and Robinson of New York have joined in with valuable 
cases in support of their contributions. We are still far from 
unanimity, and those who wish to work it out for themselves 
may consult the literature to which references are given and 

Taylor's own case, Plate LIV. of his Atlas. Also N. Y. Med. Jour., 
January 5, 1889; Tilbury Fox's Atlas, Plate XXXIX. (back of the hand), 
better shown in Annates de Derm., 2d series, vol. x., Plate III. 
Author's Atlas, Plate XXXIII., Figs. 1 and 2, shows well the palmar 
condition and the typical papules in an early stage. The comparative 
study of these plates will do more to convince the student of the unity of 
the disease under its several designations than reams of letterpress. 
Kaposi " Ueber die Frage des Lichen," Archivf. Derm. u. Syph., vol. 
xxi. (1889), p. 743; and vol. xxxi. (1895), in " L. Ruber Acum. u. L. Ruber 
Planus." Hans von Hebra, " Lichen Ruber and its connection with 
Lichen Planus," Brit. Jour. Derm., March, 1890. Neumann, " Ueber 
Lichen Ruber Acuminatus, Planus, und Pityriasis Rubra pilaire," 
Archiv f. Derm. ji. Syp/i., vol. xxiv. (1892), p. 3. " Zur Stellung der 
Pityriasis rubra pilaris, u. des Lichen Ruber Acuminatus." Neisser, 
"Zur Frage der Lichenoiden Eruption," republished from Trans, of 
Fourth German Derm. Cong. Also in Trans. Derm. Section, xi. Int. 
Cong., Rome, 1894. Besnier's valuable monograph republished from 
Annates de Derm. u. Syph., vol. x. (1889), with colored illustrations, 
gives a very complete clinical account, and the history to date. Also a 
resume in Kaposi Besnier-Doyon ed. (1891), vol. i. p. 385; Brocq, 1892, p. 
644; and various monographs. R. W. Taylor, "Lichen Ruber as 
observed in America, and its distinction from Lichen Planus "; very well 
described and highly illustrated cases in the N. Y. Med. Jour., January 
5, 1889, with histology. A. R. Robinson, " The Question of Relationship 
between Lichen Planus and Lichen Ruber," Jour. Cut. and Gen.-Ur. 
Dis., vol. vii. (1889), January, February, and March, colored illustrations. 
27 



4i 8 DISEASES OF THE SKIN. 

others which open out from them, but the following is the out- 
come of it all, as I view it. 

The identity of the lichen ruber acuminatus of Kaposi with the 
pityriasis rubra pilaris of the French school was no longer open 
to doubt to those who were present at the Dermatological Con- 
gresses of 1888 and 1892. At the latter the same case was 
claimed by the respective parties for their own disease. There 
remained the question whether Hebra's lichen ruber was the 
same disease as Kaposi's lichen ruber acuminatus. The latter 
said it was, and having worked with Hebra for so many years, 
he of all men ought to know. The difficulty is that Hebra's 
first thirteen cases, which Kaposi never saw, were attended with 
grave constitutional symptoms and ended fatally, which is 
scarcely, if ever, the result of lichen acuminatus. As we see it 
now, it is considered to be a comparatively benign disease as far 
as general symptoms are concerned. Moreover, Hebra him- 
self in his latter descriptions mixed up Wilson's lichen with his 
own disease, and possibly some other conditions as well. For- 
tunately, however, Hebra has published plates of two * of his 
early cases, which show that they were identical with those of 
the other German, French, and American w r riters. 

The above brief historical sketch was necessary because in 
the second edition of this work the descriptions of the French 
and German authors were provisionally kept apart until the 
matter was more completely threshed out. 

Of late years, although the disease is a rare one, a good 
many cases have come under my notice in my own practice and 
that of others, but I still adhere to Brocq's description in the 
main, supplementing and commenting upon it when English 
experience differs from his. 

Symptoms. — The most characteristic feature of the disease is 
the development of hard, dry papules seated at the hair follicles; 
they may be pale yellow, pale pink, red, or brownish-red, and 

* Barensprung's and Hebra's Atlas, Erlangen, 1869, Plates XIV. and 
XV. Only two fasciculi of this little-known Atlas were published. 
Plate XIV. shows the fine papules on the trunk and the scaly incrusta- 
tion of the face so often depicted and described by French authors in 
pityriasis rubra pilaire; while Plate XV. shows the closely serried rows 
of dull red rounded papules, exactly like R. W. Taylor's case, loc. cit. 
French authors claim Taylor's case as identical with Devergie's pityriasis 
rubra pilaire. 



LICHEN A C I 'MIX A T US. 



419 



with a lens show an atrophied hair in the center, surrounded 
by a sort of horny sheath, which penetrates into the follicle. 
The papules vary in size from a small pin's head to a millet- 
seed, occasionally to a hemp-seed, and are seen most abun- 
dantly on the limbs, chiefly on the back of the hands and on the 
first, and slightly on the second, phalanges, the wrists, fore- 
arms, elbows, and knees; on the body they are most abundant 
about the waist and lower part of the abdomen, but are not 
confined to these regions, and are often in the most typical 
form on the upper part of the trunk. 

These papules are not the primary phenomena, as a rule; 
more frequently the first parts attacked are the palms and soles 
with scaly patches like psoriasis palmse, which afterwards coa- 
lesce, and the whole of the palms and soles are diffusely red, 
and more or less rough or scaly, and subsequently keratosic. 
Or the onset may be on the scalp with an apparently seborrhea 
sicca, which may form a thick, whitish, adherent crust, or, 
which is less frequent, the face is the first involved, and the 
forehead and orbit become covered with fine, firmly adherent 
scales, which ultimately spread all over on the limbs and trunk. 
The characteristic conical papules soon follow, and as the dis- 
ease progresses, they become first rounder and then flattened 
(Taylor), increase in numbers, crowding together until they be- 
come confluent patches with discrete papules round. The 
patches are pale or yellowish-red, sometimes deep red, slightly 
thickened, and uniformly covered with scales, which are usually 
fine and branny, very like psoriasis on the elbows and knees, 
but they may be glistening and adherent, or in rare instances 
flaky. Deep folds are formed at the joints, and the enlarged 
papillae may have an ichthyotic appearance. Pruritus is absent 
or only slight. In extreme cases the eruption is universal, and 
the whole surface dry and scaly like a pityriasis rubra, and at 
the worst, small blackish conical elevations may be found round 
the hairs on the back of the fingers. The face, if attacked, may, 
according to Besnier, be either white with fatty scales, or red 
and branny, xerodermic, or present a combination of these 
alternations. The nails are softened, grayish, with longitudi- 
nally yellowish striae. Neumann says the nails are raised up 
by new nail substance, and laterally compressed, a condition 
I have also met with, the color being opaque yellow. There 



420 DISEASES OF THE SKIN. 

may be hy paridrosis, but the general health is often good. The 
course is slow, irregular, and uncertain, from temporary ameli- 
orations, even apparent cures being followed by inexplicable 
aggravations or recurrences. 

I have seen a case of the xerodermic type in which the whole 
face was pale red and brannily scaly, while typical papules of a 
yellowish tint thickly covered the upper part of the chest in 
rows and groups, while they were only scanty on the limbs. 

In another case, while the papules were convex or conical 
above the level of the umbilicus, below it they were flat and cir- 
cular in outline, and had a horny punctum in the center slightly 
projecting above the rest of the papule. It is the presence of 
these flat round papules along with the conical ones which has 
led some authors to regard these cases as a combination of 
lichen planus and lichen acuminatus,* but there are never flat 
circular papules in large numbers in lichen planus, the outline 
of the papules being angular in this disease. 

In a third case there was a dense scaly crust over the elbows 
and knees, very like a psoriasis at first sight, but denser and 
more ichthyotic in character, but the redness of the rest of the 
leg distinguished it from ichthyosis. On the chest also there 
was an inserted triangle of dense scaliness, but on the shoulders 
the papules were distinctive. The case subsequently developed 
into pityriasis rubra, and the papular origin was quite lost. 

In a boy, with a very partial attack affecting the face and 
upper part of the trunk, there were a large number of papules 
of lichen spinulosus about the neck and shoulders. In Taylor's 
case the papules were of a brownish-red hue, and in some parts 
in closely serried rows in the natural lines of the skin, exactly 
like one of Hebra's cases. In a case sent to me by Savill the 
onset was marked by prostration, malaise, and vomiting, and 
other digestive derangements, and it ran a short course. Of 
late too much stress has been laid on the absence of constitu- 
tional symptoms; while true of the majority of cases, much 
depends as to whether the disease develops slowly or rapidly. 

Lichen ruber, as Hebra described and named it, when gen- 
eral, is attended with severe symptoms, such as shivering, 

* Kaposi, C. Boeck, and Hans Hebra may be specially noted as having 
published such cases, also Hallopeau, but he agrees with my view that 
there is not a combination of two diseases. 



LICHEN ACUMINATUS. 



42 



rigors, general aching, and itching, followed by profuse perspi- 
ration. 

The eruption consists of disseminated, firm, conical red 
papules, from a pin's head to a millet-seed in size, smooth at 
first, but soon capped with minute scales. They feel, when 
closely set, like a nutmeg-grater, but at first they are widely 
separated, the intervals becoming gradually filled up with fresh 
papules, which itch intensely. The process is rather acute at 
first, and spreads over the whole trunk, though occasionally it 
affects the flexures alone. By a repetition of the process the 
whole skin may be involved, so that it becomes reddened, scaly, 
and much thickened, at first in patches, and ultimately in a 
diffuse infiltration interfering with the movement of the joints. 
The skin of the palms, ;>oles, fingers, and toes is worse than the 
rest, and deep fissures extend to the corium. The nails of both 
fingers and toes are affected, being sometimes of a dirty brown 
color, rough, flaky, and breaking off short, and much thickened 
if the nail-bed is involved; while, if growing out only from the 
matrix, they are thin, brittle, longer than the finger, and lighter- 
colored than normal. The larger hairs of the head and trunk 
are not involved. The worst form of the generalized disease, 
if untreated, leads to marasmus and death, but even in these 
cases the controlling power of arsenic and judicious local treat- 
ment have materially improved the chances of cure. 

The above follows Hebra's description of the most severe 
forms,* but all these developments are only seen in old-stand- 

* Neumann draws the following distinctions between lichen ruber and 
pityriasis rubra pilaris. Comparing the papules on the trunk, those of 
L. ruber are persistent, pin's-head-sized, brownish-red, and glistening, 
but slightly scaly, with a central pit. When they disappear they leave a 
brownish-red, deeply furrowed, infiltrated surface. In P. rubra pilaris 
the papules in this part are punctiform, with thin scales; they soon 
flatten down, and leave a soft, non-infiltrated, pale red, scaly surface. 
On the forearms the papules are larger, and on the' backs of the 
phalanges millet-seed-sized, and when the scale comes off are pitted, 
so that the surface is cribriform. The papules are limited to the hair 
follicles. 

In L. ruber the nails are yellowish-brown, thickened, brittle, and 
uneven, while the thick hairs are unaffected. In P. rubra pilaris the 
nails are only secondarily affected, being raised up from beneath by new 
nail substance, and laterally compressed. In universal L. ruber nutrition 
is profoundly affected. In P. rubra pilaris it is unaffected. Itching is a 



422 



DISEASES OF THE SKIN, 



ing cases. If suitably treated, it will not attain to this inten- 
sity, and may be cured fairly easily. In milder cases the face 
may escape or be simply scaly, the palms and soles also are 
only badly attacked late in the disease, but flat, transparent 
papules on the palms and soies and flat, itching erosions on the 
tongue, are described by Unna as occasional manifestations. 

Etiology. — Practically nothing is known as regards the eti- 
ology of either the mild or severe cases. It is much more fre- 
quent in Vienna and Paris than in England, and is more com- 
mon in males. 

It generally attacks young adults, but is not uncommon in 
older persons and may be met with in childhood; the youngest 
was a case which West showed at the London Dermatological 
Congress of 1896, aet. three years, and one by Rasch * of 
Copenhagen, who records a case of a child of two and a half 
years. 

The characteristic papules on the back of the fingers are 
often absent in young children, probably from the imperfect 
development of the hair follicles, but du Castel £ had a case of a 
child of five with the disease of two months' duration in which 
the characteristic papules on the back of the fingers were well 
marked. The case commenced with redness and complete des- 
quamation of the palms and soles, leaving the surface bright 
red, dry, and thinned. 

The pathology is unknown, but in my opinion it has no rela- 
tionship to lichen planus. 

Anatomically, according to Jacquet and Taylor, there is an increased 
cornification of the epithelial wall of the orifice of the follicle, to which 
the dermal inflammatory changes are probably secondary. Unna states 

marked symptom in L. ruber; in P. rubra pilaris there is no itching or 
other subjective symptom. Arsenic is almost a specific in L. ruber; it is 
often injurious in P. rubra pilaris, and must always be given with 
caution. 

Emollient applications smooth down the papules of P. rubra pilaris, 
but have very little effect on L. ruber. 

The above is in my opinion arrived at by comparing extreme examples 
of the two conditions, and if the intermediate links are studied the dis- 
tinctions break down. 

* Dermatologisches Centralblatt, second year, No. 7. Abs. Brit. Jour. 
Derm., vol. xi. (1899), p. 449. 

f Annales de Derm, et de Syfih., vol. x. (1899), p. 444. 



LICHEN ACUMINATUS. 423 

that the horny papule may form at a sweat orifice as well as at a hair 
follicle, or independently of either, that there is also a general hyper- 
keratosis of the surface, and that the redness of the skin is without a 
corresponding inflammatory infiltration. The last statement cannot be 
true for all cases, as in some inflammatory phenomena are undoubtedly 
present. 

In Hebra's form the anatomy has been repeatedly investigated by 
Neumann, Biesiadecki, and others; their observations, made in an 
advanced stage, showed a chronic inflammatory process deep in the 
corium, in and around the hair follicles, whose sheaths by proliferation 
of the cells were enlarged into knob-like and spigot-shaped excrescences. 
The other changes were such as may be found in other chronic forms of 
dermatitis, e. g., prurigo. 

Diagnosis. — The characteristic features are: in mild cases, the 
follicular papules, with a horny plug in the orifice of the follicle, 
which can be picked out, and produces a cribriform aspect; the 
dry scaliness of the palms, soles, scalp, and face; the incon- 
spicuous inflammatory changes ; and, finally, the absence of any 
disturbance of the general health — in other words, its benign 
course as compared to most forms of universal dermatitis. In 
the severe form the development is often rapid, with marked 
constitutional symptoms, and the papules are crowded together 
like a nutmeg grater, and often are of a dull red color. 

The diseases it most resembles are pityriasis rubra and 
psoriasis, and some of the slight cases resemble a mild form of 
ichthyosis. 

From pityriasis rubra it would be distinguished by the trifling 
hyperemia as a rule, the small scales, the presence of the papules 
and of the diagnostic blackish cones on the back of the fingers, 
the absence of constitutional disturbance, and its uniformly be- 
nign though chronic course. 

Only the most crusted cases would be mistaken for psoriasis. 
There is not the spongy character in the dense crusts, some of 
the characteristic papules could be found somewhere; and the 
peculiar incrustation about the face and scalp would be present. 
Onlv the mildest cases would be mistaken for ichthyosis. There 
is sure to be some redness, though it may be slight, and the 
development would be comparatively recent instead of dating 
from infancy, as ichthyosis does. 

Prognosis. — Most cases run a slow course, ultimately ending 
in recovery unaided by treatment, but relapses may occur even 
after years of freedom. Cases of rapid development and in- 



4 2 4 DISEASES OF THE SKIN. 

volving the entire cutaneous surface may be fatal, as in Hebra's 
series, but they are quite exceptional. 

Treatment. — Effort should be made to restore the sweat secre- 
tion by subcutaneous injections of pilocarpin nitrate gr. 1-6, 
and active exercise combined with alkaline baths, frictions with 
soft soap, followed by pyrogallic acid, which Brocq says is 
especially efficacious, or oil of cade or resorcin, which can be 
used over larger surfaces than pyrogallic acid, or mercurial ap- 
plications, which are also valuable for limited areas. In short, 
the treatment is that for psoriasis, except that arsenic is contra- 
indicated in an early or developing stage on account of its 
tendency to increase keratinization of the tissues, which is al- 
ready excessive, and marked aggravations have followed its in- 
judicious use. Brocq says, however, that arseniate of soda 
may be beneficial sometimes, if given cautiously. 

I have found the administration of thyroid extract a valuable 
adjuvant to local treatment. As usual, the initial dose should 
only be five grains a day, with a weekly increment according to 
the tolerance of the patient, and it is rarely necessary to ex- 
ceed fifteen grains a day. Graham Little has had a good result 
in one case with thyroid. If active inflammation sets in, the 
treatment would be that for pityriasis rubra. 

In the severe Hebra type the Vienna authorities consider 
arsenic a specific for the disease, until it has gone on too far, 
so that the patient is emaciated and exhausted. Hebra lost all 
his generalized cases until he tried arsenic. 

This discrepancy in the effect of arsenic is one of the chief 
arguments of those who still hold that lichen ruber and lichen 
acuminatus are different diseases, but is, in my opinion, of small 
weight, as it is common to see the same drug aggravate one 
stage or form of a disease and ameliorate another. Arsenical 
advocates say that it may be needful to give it in heroic doses 
for a long period in the form of liquor arsenicalis (n\v to TTLxv, 
or more if the patient's stomach can bear it, three times a day, 
of course largely diluted), or, as Kobner suggests, TTLiv of 
Fowler's solution to Tr^xx of distilled water injected hypoder- 
mically every day for three or four weeks, or in the form of 
Asiatic pills, three, gradually increasing to ten a day, each pill 
being equal to one-twelfth of a grain of arsenious acid. Ka- 
posi gave as many as 4500 of these pills before a cure was 



LICHEN PLANUS. ■ 425 

effected, and without evil consequences. Personally I should 
defer using it until other means had failed. Arsenical hypo- 
dermic injections are very painful. 



LICHEN PLANUS.* 

Synonyms. — Lichen ruber planus; Lichen psoriasis 
(Hutchinson). 

Definition. — Lichen planus is characterized by the presence of 
inflammatory papules, of which the most characteristic are flat 
and angular, either discrete or confluent, and of some shade of 
red. 

Lichen planus was first described by Erasmus Wilson, and is 
in the great majority of cases a well-characterized affection. 
It is a rather uncommon disease, forming one per cent, of hos- 
pital cases and two per cent, in private practice in this country. 

L. planus may be acute and general, or chronic and limited 
to a few regions. The chronic is by far the more frequent, and 
will be first described. 

Symptoms. — Lichen planus presents itself under two aspects, 
viz., papules and patches, the patches resulting from the aggre- 
gation of the papules. It is usually localized to a few regions, 
but it may be general. 

It appears as flat, slightly raised, discrete papules, varying 
from one-sixteenth to a sixth of an inch in size, of angular out- 
line, smooth, shiny surface, with a minute horny punctum or a 
small depression in the center of many of them, and of a lilac 
hue, which is very suggestive of the disease. In fully devel- 
oped papules Wickham's signs of striae and grayish puncta on 
the surface of the papule may be recognized. The angular 
shape is determined by the boundary lines being formed by the 
slightly deepened natural lines of the skin. 

* Author's Atlas, Plate XXXII., Fig. 1, illustrates a subacute case with 
slightly scaly papules (unusual); Fig. 4, the hypertrophic form, Plate 
XXXI. shows a generalized acute miliary L. planus; and Fig. 3, Plate 
XXXIII., a generalized less acute form. Owing to the small size of the 
primary lesions and their shining appearance, it is impossible to give an 
accurate delineation of their characters, and only the general aspect and 
arrangement is portrayed in any Atlas in which the attempt has been 
made. 



426 DISEASES OF THE SKIN. 

They are either scattered, or arranged in irregular groups, 
lines, bands, or circles. The lines usually run transversely to 
the limb, determined also by the natural markings of the skin, 
but traumatism, chiefly friction or scratching, may determine 
the direction of lines in the length of the limb, and bands of 
eruption generally run parallel to the limb axis. 

By the close aggregation of the papules, and by their increase 
in number, not in size, patches are formed, generally of small 
area, but large sheets of infiltration may be produced. These 
patches present a very different aspect to the papules. When 
small they may be roundish, with a depressed center, butswhen 
large they have an irregular, well-defined outline, are raised 
considerably above the surrounding skin, have a purplish hue, 
and are covered with thin scales, a feature rarely seen in the 
papules. 

The commonest situations for the eruption, and where it 
most frequently commences, are the flexor aspect of the wrist 
and forearm, and next the inner side of the knee, but no exter- 
nal part of the body is altogether exempt from attack, and even 
the mucous membranes are involved in many cases. 

Next in order of frequency to these two positions come the 
leg below the knee, the ankle and foot, the extensor surface of 
the arm, the flank, hip and lower part of the abdomen, the 
palms, soles, and wherever there is friction or irritation. The 
rarest seats on the skin are the face and scalp, fingers and out- 
side of the lips. When the fingers are attacked, the nails also 
may become involved, but there is nothing distinctive. 

Symmetry, more or less obvious, is the rule, but the lesions 
may be unilateral; and sometimes the eruption may remain 
limited to a single patch for a long time before other papules 
and patches appear. 

The papules and patches on their disappearance leave behind 
them slight atrophic depressions, with long persistent stains, 
varying from a fawn color to a bluish-black tint, according to 
the duration and severity of the inflammation. 

Itching of moderate intensity is generally present, and may 
precede the eruption; occasionally it may be intense, and is very 
rarely absent altogether; sometimes no defect of the general 
health can be detected, but more often there is some, usually in 
the direction of neurasthenia or dyspepsia. 



LICHEN PLANUS. 427 

Course. — The disease may last for years, and if untreated 
tends to spread; and even with suitable treatment requires sev- 
eral weeks, or even months, for its removal, while the most 
severe generalized form may lead to marasmus and death. It 
recurs in some people,* but at much longer intervals than in 
psoriasis, and not so frequently. 

The acute form (acute miliary lichen planus) may be primary 
or supervene on the chronic form, but not necessarily spread- 
ing directly from the old patches. It is less frequent, not more 
than one to ten of the slower form; it generally commences on 
the limbs, but may affect the trunk first. It spreads slowly or 
rapidly; in the latter case, perhaps covering the whole body in 
a few days, or even within twenty-four hours. In these, which 
may almost be called malignant cases, there may be pronounced 
constitutional symptoms: febrile disturbance and profound 
bodily and mental depression, sometimes resulting in temporary 
insanity, and either a very prolonged convalescence, or in rare 
instances, death by marasmus or complications. These symp- 
toms suggest toxic effects, either primary and producing both 
constitutional symptoms and rash, or secondary, from the sud- 
den disablement of the whole cutaneous envelope. In the ma- 
jority of cases the constitutional disturbance is seldom very 
pronounced at first, but itching is nearly always a prominent 
symptom, and may be very severe, and by the loss of rest it 
occasions be of itself a cause of a serious aggravation of the 
general symptoms. Although acute in its development, it is 
often chronic in its course, unless the patient takes to his bed, 
and submits himself to appropriate treatment. The face and 
scalp are seldom attacked, and the palms and soles often escape. 
The rest of the body, including the neck, is more or less impli- 
cated, but there are generally clear areas. The lower half of 
the body and limbs is usually more affected than the upper. 
The papules are usually small, flat, or slightly convex, angular, 
shining, and of a very bright red, and this is the only condition 
in which lichen ruber planus would be an appropriate title, but 
it is better omitted altogether. There is a tendency to irregu- 
lar grouping of the papules, and to follow the natural lines of 
the skin. Although the papules may be densely crowded to- 

* In one of my patients the disease recurred every July for four or five 
years, and her first attack was fifteen years before I saw her. 



428 DISEASES OF THE SKIN. 

gether, their outline is generally distinct for a long time nearly 
all over the body; but when the disease has lasted some time, 
the papules coalesce and become covered with small scales, 
which may almost conceal the red surface beneath. Hallopeau 
has had three cases with a general redness of the skin, in which 
the papules had very slight elevation. 

Variations, etc. — When developing papules are carefully ex- 
amined with a lens, in a subacute case, only the smallest areas 
inclosed by the natural markings of the skin are involved. 
Their color is often the same as the normal skin, and they are 
recognizable only on looking obliquely along the surface, by 
their smooth shining appearance, while, when they develop 
acutely, they are bright red and often remain small; but the 
more chronic papules are built up to one-eighth or one-sixth of 
an inch by the aggregation of these minute areas, with the 
natural lines of the skin still forming the boundaries of the 
papules. Their surface is dotted with red points, representing 
the apices of the hyperemic papillae below, and minute dilated 
vessels are visible between the papules, accounting for the dif- 
fused red hue observed in some cases. The papules used to be 
described as having the hair follicles for a center, but this is sel- 
dom the case, the hair, if present, being at the side of the 
papule, and the follicle may not be involved at all. The papules 
vary from the type in color and shape, but their outline is rarely 
circular (vide Lichen Acuminatus). 

Many papules, instead of being simply angular, show minute 
processes at the edge, like a keloid on a small scale. Instead 
of being flat, they may be convex, small, large, or moniliform. 

In a gentleman * from Brazil an eruption came out soon after 
his return to England, and when I saw him eleven months later 
nearly all the body was covered with an eruption of papules the 
size of a pin's head and convex; they had some tendency to 
irregular grouping, and while at first sight they looked as if 
seated at the follicles, a lens showed that the hair was often at 
the side, not in the center, of the papule. 

In model 1435 of the St. Louis Museum, labeled Lichen 

obtusus, the papules on the arm are from a quarter to half an 

inch in diameter, and lenticular in outline. They may also be 

more or less conical and slightly scaly. These varieties may 

* Private Note-book, B., p. 147. 



LICHEX PLANUS. 



429 



occur alone, or, what is more frequent, be associated with the 
characteristic lesions in the other parts. Unna * drew special 
attention to this form after studying the above model. 

In an extraordinary case of Kaposi's, f besides the ordinary 
papules and plaques, there were thick moniliform bands in the 
flexures of the limbs, on the abdomen, and on the neck. In 
the last position, which was completely surrounded down to the 
clavicles, they were like hypertrophic burn cicatrices. Micro- 
scopically, the bands were made up of dense cell infiltration, 
chiefly in the deep part of the corium, without any connective 
tissue formation. Xo cause could be discovered for this un- 
usual development. Rona has reported a similar case to the 
Buda-Pesth Medical Society. J Dubreuilh, G. H. Fox, and 
Bukovsky have also met with similar but less extreme cases. 
It is open to discussion as to whether these cases really belong 
to L. planus ; their general arrangement and the partial involve- 
ment of the face are against it. but Kaposi described it as a 
variety of L. planus, and the others have followed him. 

L. Planus Erythematosus would be a suitable appellation 
for a very rare variety, of which I have seen two instances. In 
this the lesions are of a deep crimson tint, very soft to the touch 
instead of firm, and look more like an erythema than L. planus, 
as they can be temporarily obliterated by pressure, and the 
epidermis is evidently not involved. One case was a gentle- 
man past middle age. The eruption had existed for a year, and 
was in closely aggregated, small papules, limited to the groins 
and large areas on the trunk. The other was not under my 
care, and the disease had been present over two years, and was 
very extensive. There was also much telangiectasis of the face 
and mouth. S. Stirling § has also described a case of this 
kind. 

The papules may be pale or even white in rare cases. In a 

*" Clinical History and Treatment of 'Lichen Ruber,'" Medical 
Bulletin. Philadelphia. 1885. An interesting essay, with mam* cases. 

\ Viertelj. fur Derm, u. Syph., vol. xiii. (1886), p. 571, " L. Ruber 
Moniliformis," with colored plate. 

% Quoted by Kaposi, loc. cit., vol. xiv. (138;), p. 270. loc. cit., vol. lvii. 
Bd. 102, p. 143. Bukovsky gives references to the other cases. 

§ Trans. Third Inter. Cong. Derm., 1898. 



430 DISEASES OF THE SKIN. 

Hindoo boy of four they were so, and contrasted sharply with 
his dark skin. Harrison of Bristol wrote to me describing a 
white-papuled case in a white person. 

The position of the lesions exercises a modifying influence 
upon their aspect. Thus, upon the palms and soles, there is 
only thickening of the epidermis, with perhaps white spots 
where the horny layer is cracking. On mucous membranes the 
sodden papules look white. Lichen hypertrophicus is much 
more frequent on the lower extremities, and lichen verrucosus 
is seldom seen above the knee. 

Dubreuilh * records it as affecting the nails, but there was 
nothing distinctive. 

L. Planus Hypertrophicus. When the disease has exicted 
for a long time, — and it may last an indefinite number of years 
if untreated, — the papular part clears up, leaving the patches, 
which undergo great thickening, often caused and always ag- 
gravated by scratching. In some cases with severe pruritus 
the thickening may occur quite early. 

The patches when isolated are roundish or elongated, con- 
siderably raised above the surface, rough from small horny ad- 
herent scales, and of a purplish hue. This is especially marked 
about the lower third of the leg, its usual position, but it may 
occur in any part of the lower and sometimes on the upper 
limb. By coalescence of the primary patches large areas of in- 
filtration are produced. When these lesions, which are largely 
epidermic, are removed or clear up very deep pigmentation and 
even atrophic scarring is left. 

L. Planus Verrucosus is sometimes only a variety of hyper- 
trophic lichen, in which the papillae of the skin are enlarged and 
have an irregular wart-like horny covering. Warty patches may 
also form primarily, from the aggregation of papules developing 
round the hair follicles of the lower extremity (rarely on the 
upper limb). These papules have not the characters of the 
usual form of L. planus, but are acuminate or conical, with cen- 
tral horny projections, and therefore like a nutmeg-grater to 
the touch, and may be rounded in outline. If they enlarge 
peripherally they tend to flatten out, but they usually coalesce 
* Annates de Derm., vol. ii. (1901), p. 606. 



LICHEN PLANUS. 



431 



into a considerably projecting patch, with a very rough irregu- 
lar horny surface of a dirty greenish or brownish hue. 

Similar papules, single or in regular aggregations, but re- 
maining discrete, may sometimes be seen interspersed with ordi- 
nary L. planus lesions, and the latter are almost sure to be pres- 
ent in some part of the body when lichen verrucosus is present. 

Lichen Planus Sclerosus, seu Atrophicus, seu Morphceicus. 

Morrant Baker in 1882 had a case of this, but Hallopeau * in 
1889 first published and described the condition, and he has 
had two cases since; Stowers showed a well-marked case to the 
Dermatological Society of London. Baker's case was com- 
posed of white, oval or round, convex, solid papules, in sym- 
metrical groups of irregular shape, on the tips of the elbows 
and knees, the wrists, and back of the hands and feet. There 
were minute vessels between the papules. Usually, however, 
they are flat and angular, firm to the touch, and bend with the 
skin, the seat of election being the lower part of the forearm. 
In the center is a horny plug, and if this is removed it leaves a 
hole with a distinct horny wall. The papules are often of a 
nacreous white, very like morphea, from which it may be dis- 
tinguished by the horny plugs and the component papules 
being visible, especially when they run together, though their 
outline is seldom wholly lost. There is no clinical sign of in- 
flammation. Hallopeau describes the mode of development. A 
black, slightly projecting horny point forms; it has a bright red 
areola, which lasts several months, and is united to similar 
more recent lesions. The black projections fall out after some 
months and the eruptive plaque is decolorized. There is mod- 
erate itching only. Darier's histological observations in one 
of Hallopeau's cases show that the difference lies in the active 
inflammatory process being more deeply situated than usual, 
and the production of fibrous tissue in the papillary layer. 
There may be lesions of the buccal mucous membrane of the 
usual lichen planus description. 

On Mucous Membranes, f It is not infrequent, and espe- 

* Hallopeau's third case, Annates de Derm., January, 1896, vol. vii. 
Zarubin's case of L. ruber planus atrophicus was different and had red 
papules. Archivf. Derm., vol. lviii. (1901). p. 323, colored plates. 

f Author's Atlas, Plate XXXVII., Figs. 3 and 4, palate and tongue, and 
Plate LXXXVIII. Figs. 4 and 5, tongue and buccal mucous membrane. 



43 2 



DISEASES OF THE SKIN. 



cially when upon the penis may precede the skin eruption by 
some weeks or months. It is often most marked in the mouth 
when there is but little eruption of the skin, and may be quite 
absent in the most generalized cases. On the tongue it usually 
appears as ill-defined opaque white spots, symmetrically placed 
on each side of the raphe and scarcely raised above the surface; 
but in one case of mine there were in addition to the white spots 
smooth, flat, angular, very slightly raised papules of the same 
color as the rest of the tongue. On the buccal mucous mem- 
brane white branching streaks may not infrequently be seen, 
most marked opposite the teeth. Inside the lips it is in minute 
specks, and on the palate I have seen it in a mosaic with white 
outlines. On the penis the appearance varies, being white or 
of the usual color, according to whether the glans is covered 
by the prepuce or not; i. c, whether the part is moist or dry, the 
glans being the usual site of the eruption. In a little girl under 
my care the eruption had the aspect of white spots inside the 
vulva; moreover, I have seen it on the outer side of the vulva 
in the adult. 

L. Planus Annularis. — It has been mentioned that the 
lesions may be in the form of rings; one or two here and there 
are not uncommon, but in a few cases they are very numerous, 
and are a striking feature in the case. They are seldom large, 
a quarter to three-quarters of an inch is the usual size, and the 
ordinary papules are always present. Cavafy closely observed 
a well-marked case, in which the rings were strongly developed 
on the trunk, and affirms that they are formed in two ways, (i) 
" by the direct confluence of papules into rings, and (2) by 
gradual peripheral extension of large flat papules, accompanied 
by involution of their central portions. The former arrange- 
ment obtains on the trunk, the latter on the forearm." The 
rings have a firm, very narrow raised border, sometimes show- 
ing traces of their compotent elements. Brooke and Engman * 
have also observed the second and unusual mode of develop- 
ment; the latter affirmed that the peripheral activity and cen- 
tral involution began at an early stage, and not by the involu- 
tion of a fully formed plaque. Engman examined a ring histo- 
logically. 

* Engman, Amer.Jour. Derm, and Gen.- Ur. Dis. t vol. xix. (1901), p. 209. 



LICHEN PLANUS. 



433 



Linear L. Planus. Not only may the individual papules be 
arranged in lines, but the grouped elements may form striae, or 
bands, in the course of nerves, or, as some consider them, in 
Voigt's lines, i. e., the boundaries of the areas included in a 
cutaneous nerve domain. Although such cases are rare, there 
are a good many recorded, owing to their striking character. 
The most favored position is in the course of the small sciatic 
nerve from the buttock to the middle of the calf. Branches of 
eruption from this may pass upwards to the genitals or down- 
wards to the heel and along the foot. Such cases were known 
to Cazenave and Devergie * as " Lichen en ruban." The latter 
quotes a case with the sciatic distribution by Faget in 1843. 
A similar distribution has been noted in other eruptions, and is 
especially frequent in ichthyosis hystrix striata. 

In a lady of fifty, sent to me by my friend Gilbert Smith, a 
succession of connected rings of eruption extended from the 
vulva downwards and backwards to the middle of the calf, ap- 
parently following the course of the small sciatic nerve. The 
borders were composed of brownish-red, flat papules, with yel- 
lowish staining in the center. There were abundant character- 
istic L. planus papules on the abdomen. The patient was a 
highly neurotic subject. 

Morris, Pringle, Galloway, Meyer, and Heller of Berlin f have 
met with cases with a very similar distribution, and in Meyer's 
case the eruption generalized while under treatment. In an- 
other of my cases it began just below the left buttock, and ex- 
tended downwards and forwards in streaks to the anterior sur- 
face of the thigh as far as the beginning of the lower third. 
The eruption consisted for the most part of characteristic 
lichen planus papules, but there were also some acuminate 
papules with horny centers intermingled. In a third case, a 
girl of twelve, it extended from the center of the fork down the 
inner side of the thigh to the lower third, and from the inner 
and lower border of the popliteal space to the back of the inter- 
nal malleolus, in the course, therefore, of the internal cutaneous 
and saphenous nerves. 

In Mackenzie's case the eruption was in the course of the 

* Devergie, " Maladies de la Peau " (1854), p. 449. 

\ Archiv f. Derm. u. Syph,, vol. xlii. (1898), p. 59, with photograph and 
microscopic plates and references to cases with similar distribution. 
28 



434 DISEASES OF THE SKIN. 

left ulnar and internal cutaneous nerves ; in another it began in 
the course of the intercostal nerves like a herpes, and subse- 
quently, after a long interval, became general. Similar cases in 
other positions are on record, as in L. Fournier and Paris's case, 
on one side of the neck in the course of the superficial cervical 
plexus in front, and the third to the eighth cervical behind. 

Complications and Sequela. — Bullae are sometimes observed in 
the course of lichen planus, either on the free skin or where 
the papular eruption is already developed, but in a case of Bes- 
nier's related by Darier, and in Rona's case, an outbreak of 
bullae preceded the appearance of the usual typical papules. 
Kaposi and Leredde have also had striking examples of the 
bullae having been associated with the papules from the com- 
mencement. As a rule, the bullae are few in number, from a 
quarter to half an inch in diameter, with clear or slightly blood- 
stained contents; but in Kaposi's* case they were extremely 
numerous, and actually masked the lichen planus condition for 
a time. Many of the cases have taken arsenic for some time 
before the bullae appeared; but while it is possible, as C. Fox 
suggests, that it may be a predisposing factor, I can, from per- 
sonal experience, affirm that in some cases no arsenic has been 
given, f 

According to Ciarrocchi, milium may follow lichen planus as 
it does sometimes pemphigus. Keratosis palmae and plantae 
may be present in a high degree in some acute general cases. 
In one patient of mine the keratosis was great, there was pur- 
plish redness round, and there was profuse hyperidrosis of the 
hands. The thickened part was thrown off in large masses as 
he improved. Similar cases are on record. The horny puncta 
of the papules are sometimes unusually prominent, amounting 
almost to spininess; they are usually shed in the course of the 
eruption, but in one of my cases persisted after the surrounding 
papules had subsided. Soft soap frictions soon removed them. 

Very distinct sepia pigmentation is the rule, but in some cases 
it is more intense, a bluish-black color being left which is very 
slowly absorbed. 

*Hand Atlas, Plate 171. 

fin Brit. Jour. Derm., May, 1902, with many references, Whitfield 
found that no arsenic had been given in nine out of seventeen cases. In 
a bulla examined, the whole epidermis was raised up. 



LICHEN PLANUS. 



435 



So, too, atrophic shallow pits are commonly observed after 
the eruption has subsided, but it usually only affects the epi- 
dermis and upper part of the papillary layer, and the loss of 
tissue is soon restored. Occasionally, however, tne process 
goes deeper and permanent scarring results. This is not very 
rare after the hypertrophic form on the legs, and the scar is 
then pigmented, but it may also occur even where there have 
only been papules. Kaposi and Brault * have recorded cases 
in which, during a recurrence, the scars of a previous attack were 
observed as distinct white pits. I have only seen it after 
patches, not from papules alone. 

Children. — When occurring in children — a rare event — the 
disease takes the same characters and follows the same course 
as the acute and chronic form of adults. 

There is, however, a spurious infantile form which is different 
in development and course. After closely observing this for 
some years at the East London Hospital for Children, I am 
convinced that it is only the subsiding stage of a miliaria rubra, 
either papular or vesicular, in which the top dies down and a 
scale comes off, leaving a smooth, shining, angular, flat, very 
slightly raised papule, of a brighter red than usual, though it 
may get a purplish tint subsequently. It may be on the limbs 
or trunk, or both, is attended with considerable itching, and 
gets well in a few weeks with the help of a soothing application, 
such as calamin lotion and a ferruginous tonic. 

It occurs most frequently in infants who sweat profusely, and 
is, therefore, common in rickets, and probably a sudden chill 
while in a profuse perspiration is the determining factor. 

Liveing and Colcott Fox \ have written on this form. It is, 
however, omy noteworthy in diagnosis, and is not a disease of 
itself. Nevertheless, true lichen planus does occur as a rare 
event in infants. Kaposi had a case in which the child was 
only eight months, and Hallopeau % one of twelve months. 

Etiology. — The most common cause is nervous exhaustion, for 
which " neurasthenia " or " nervosisme " are the euphemisms. 

* Kaposi's case is related in his Lectures, and Brault's is recorded as a 
case of lichen planus sclerosus in Annates de Derm, et de Syfih., vol. v. 
(1894), p. 834. 

f " Notes on Lichen Planus in Infants," Brit. Jour. Derm., July, 1891. 

% Annates de Derm., vol. i. (1900), p. 225. 



43 6 



DISEASES OF THE SKIN. 



It is consequent upon worry, anxiety, or overwork, deficient 
food, etc., especially in a nervous temperament, but derange- 
ments of the digestive or generative system are not infrequent, 
while in many cases no cause whatever can be made out, the 
patients being young and vigorous subjects, free from neurosis 
in any form. The acute general cases are, I believe, often de- 
termined by a chill during perspiration, especially in persons 
who have already had chronic patches. 

Age. — It occurs mainly between thirty and sixty, and it is 
more frequent between forty and fifty than in the other decades 
above and below that one, in which the numbers are about 



& 




Fig. 24. — A recent papule of lichen planus. X 120. 

b, copious round cell infiltration lifting up epidermis into a papule; c % 
blood-vessel; a and d, several ducts traversing papule. 



equal. The extremes I have seen are three and seventy-four 
years, but younger ones are recorded (see under Children). 

Sex. — In England it is more frequent in women. In 114 
hospital cases the women were as 7 to 4, and in 108 private 
cases as 8 1-2 to 7, and other English cases tend in the same 
direction. In Vienna just the reverse holds good; Kaposi says 
two-thirds are males. Possibly the much greater frequency of 
the L. acuminatus there may account for the discrepancy, as 
that seems undoubtedly more common in males. 

Traumatism in the shape of scratches and friction will de- 
termine the development of L. planus in the locality and direc- 
tion of the damage in a person in whom the disease already 
exists, and in a case of S. West's a scratch of a cat excited an 
eruption in the scratch lines in a woman who had no previous 
eruption, and subsequently other lesions formed where there 



LICHEN PLANUS. 



437 



had been no scratching. Jacquet goes further than this, and 
says that all lichen planus is traumatic in this sense in a skin in 
which the vaso-motor tonus is diminished under a central nerv- 




ous influence, and that a dermographic lichen planus can be 
produced just as a dermographic urticaria. This is in my 
opinion an over-statement of the case, but most cases of the 
so-called Vidal's lichen are thus produced. 

Pathology. — In L. planus the process appears to be inflam- 



438 DISEASES OF THE SKIN. 

matory, beginning usually round a sweat duct in the upper part 
of the corium, with subsequent thickening of the rete, the cells 
of which are horizontally compressed by the cell mass below; 
the papillary vessels are dilated. In the infiltrations these sec- 
ondary changes form the most conspicuous part of the process. 
The pathological factor which gives rise to the inflammation 
still requires elucidation. Colcott Fox suggests that it is only 
the consequence of neuroparalytic hyperemia, and most 
French authors agree with him (vide Jacquet's theory under 
Etiology). But while the clinical facts lend some color to the 
nerve theory, it does not really explain the process, and as dis- 
turbance of the nervous system cannot of itself determine the 
form of an eruption, other factors must be necessary, and of 
these we are ignorant. The fact of its having an occasional 
nerve distribution is no ground for supposing a disease to be of 
nerve origin. 

Anatomy. — In 1881 I excised recent papules from five living patients, 
and the border of an infiltrated patch from one, and found the anatomy 
to be as follows : 

A vertical section through a recent papule of L. planus reveals a mass 
of cells like leukocytes, and embedded in this are sometimes seen frag- 
ments of the fibers of the corium, in the most superficial part of which 
the effusion has taken place. Sharply limiting the cell mass below lies a 
blood-vessel, and it may be assumed that it is through its upper wall that 
the cells have passed. There are usually no cells below the vessel. 

The condition of the rete varies. When the effusion of leukocytes is 
considerable — i. <?., when the process is acute — the rete is forced upwards, 
and is very little thickened, or indeed may even be thinned in the center, 
slight thickening being evident at the sides only and in the immediate 
neighborhood of the papule (Fig. 24). When, on the other hand, the in- 
flammation is not so acute, the rete is immensely thickened by prolifera- 
tion of its cells. The thickening compresses the cell effusion below it, 
obliterates some of the papilhe, while others are enlarged by the down- 
growth of the interpapillary processes (Fig. 25). Thus, in the first case, 
the cell effusion forms the greater part of the papule, while in the second 
the proliferated rete has the larger share. 

The horny layer is only slightly thickened except in the center of the 
papule in the second phase, where it forms a sort of conical plug fitting 
into a depression of the rete, its apex corresponding with the orifice of 
the sweat duct. The desquamation of this plug affords a ready explana- 
tion of the familiar clinical feature of a central depression in the papule. 
It appears to me much more probable than Biesiadecki's theory that the 
depression is produced by the tetanic contraction of the arrector pili 
muscle pulling the surface down. The falling out of a hair does not 



LICHEN PLANUS. 439 

account for it, as the hair follicles are seldom the seat of the process. 
As seen in the figure, a sweat duct may so frequently be traced down 
the center of the papules that I cannot but think they act, at least, as 
determinants for the starting-point of the process, the deep-lying sweat 
glands being unaffected. It is common also to find a healthy hair follicle 
adjacent to the papule. The vessels are only slightly dilated in this stage. 
In a papule with a hair in the center, a comparatively rare circumstance, 
I found thickening of the rete adjoining the hair follicle, slight effusion at 
the angle of the follicle and rete, and perhaps slight thickening of the 
upper part of the former ; the lower part was entirely unaffected. I have 
only once seen a cell effusion round the transverse section of a hair follicle 
deep in the corium. In sections from the border of a patch there was 
enormous thickening of the rete, the cell effusion adjoining had under- 
gone partial fibrillation, and the vessels were enormously dilated. There 
were no hair follicles in the piece examined, and it was not sufficiently 
deep to show the lower part of the corium. Robinson of New York, 
Caspary, and Torok * have since confirmed the above statements as far as 
the anatomical facts are concerned, but Torok explains them somewhat 
differently. The older descriptions by Neumann, Biesiadecki, etc., were 
made from chronic cases of L. ruber, and are therefore totally different. 

More recent observers, Joseph, Unna and his followers, Norman 
Walker, Galloway, Macleod, etc., regard the cell infiltration to be chiefly 
derived from connective tissue cell proliferation, and the process more 
allied to a granulomatous than an inflammatory process. Galloway com- 
pares it with lupus erythematosus. It would be difficult to account for 
acute cases on the infective granuloma theory. 

Among minor points Joseph noted the breaking-down of the stratum 
cylindricum of the rete and the formation of small cavities ; an observa- 
tion also made by Whitfield. Unna noticed cystic dilatation of sweat 
coils. Joseph attributes the umbilication of involuting lesions to the 
absorption of these pseudo-vesicles ; Torok explains it as seen in well- 
developed papules by its being held down by the sweat duct, which seems 
to me very improbable. Unna considers the shining aspect of the pap- 
ules is due to the stretching of the epidermis by the subepidermic infil- 
tration, and Darier says Wickham's striae result from the stratum granu- 
losum being unequally thick, the thin parts allowing the vessels to show 
through. 

In L. verrucosus Joseph f describes enormous thickening of the 
stratum corneum and granulosum ; " vesiculation " in the prickle-cell 

* " Anatomie du Lichen plan.," by L. Torok, Jour, des Mai. Cut., 1889, 
with references to literature. Also in German, illustrated in Ziegler's 
Beitrdge z. path. Anat., Band. viii. Caspary gives a figure closely 
resembling my second figure. 

f " Anatomy of Lichen Ruber Planus, Acuminatus, and Verrucosus," 
Archiv f. Derm. u. Syph. y Bd. 38, January 7, 1897. Illustrated. Abs. 
Brit. Jour. Derm., vol. ix. (1897), p. 245. Unna's Histology, 1896, gives 
references to date. 



440 DISEASES OF THE SKIN. 

layer and hypertrophy of the papilla?, cystic degeneration of the sweat- 
coils, and mononuclear cell infiltration of the hair follicles. 

Diagnosis. — In L. planus, the discrete, flat, angular, shining 
papules are, when these characters are combined, so distinctive, 
especially when they have a purplish tint and are situated on 
the wrists or over the vastus internus, that there is no disease 
with which they could fairly be confounded. 

More minute and less constant characters, requiring exami- 
nation with a lens, are a central horny point or a depression, 
and Wickham's sign of minute gray points and striae. 

Mistakes arise from taking one or two of the above signs as 
sufficient for the diagnosis. Thus flat round papules may be 
met with in lichen acuminatus, and as one of the phases of my- 
cosis fungoides * in the premycosic stage of some cases. 

Some of the patches in the hypertrophic form, when raised 
and scaly, might be mistaken for chronic eczema or psoriasis. 
The violaceous or lilac tint almost invariably present in such 
cases should suggest the possibility of L. planus, and with close 
investigation it is very rare not to find some of the characteristic 
papules or their stains in the neighborhood of the patch, or at all 
events in some other part of the body. 

Other points in the diagnosis from chronic eczema are: The 
disease began as flat papules, there has never been discharge 
nor crusts, and the position would probably be different. 

From psoriasis it began as smooth, not scaly, papules, which 
did not enlarge at their periphery. The scales on the patch 
are thin and net heaped up: on their removal their color is 
purplish or dull red, instead of bright red. Unless situated on 
the extensor aspect, the position might help here also. 

Prognosis. — This is generally good for ultimate recovery, but 
the patients often improve but slowly. 

Treatment. — The treatment in the main is on the same lines 
as that of psoriasis, except that, as a rule, the local applications' 
require to be rather milder. There are three indications to be 
followed: first, the improvement of the general health, espe- 
cially as regards the nervous exhaustion; secondly, the relief of 

* This was so in a case published by M. Morris in Brit. Med. Jour., vol. 
vi. (1894) p. 287, with colored plate, and in one of my cases of the lym- 
phangitic form. 



LICHEN PLANUS. 



441 



the itching, which of itself will promote the involution of the 
eruption; and thirdly, the employment of arsenic and other 
drugs which experience has proved to be useful; but what may 
be good for chronic is often unsuitable for acute cases. In ful- 
fillment of the first indication rest for the overwrought nervous 
system is frequently essential, and in widespread and acute 
cases bed is by far the best place for the patient; in some cases 
change of air and surroundings and improvement of the gen- 
eral nutrition and tone are the line to be followed; feeding the 
patient up with easily assimilated food frequently administered, 
cod-liver oil, nervine tonics, as iron, in full doses, quinine, the 
mineral acids, and nux vomica, may do the rest. If, however, 
the digestion is disordered, that must first be corrected by the 
removal of constipation, dieting, alkalies, bismuth, bitter 
tonics, etc. 

Arsenic used to be considered to be specific for this disease, 
but it often fails, and has in my practice been largely super- 
seded by other medicines. It is often unsuitable for various 
reasons. 

For example, in cases where an irritable condition of the 
alimentary canal exists, this must be subdued before it is safe to 
give the drug. Some patients are intolerant of arsenic, and 
there are some cases where it seems even to aggravate the erup- 
tion. Tilbury Fox seldom gave arsenic, and in many localized 
cases and in the verrucose patches its influence is very slight. 
For the less severe cases it may be said that arsenic is likely to 
be most useful in proportion to the chronicity or low intensity 
of the inflammation, where there is no defect of the general 
health that can be better removed by other means. Liveing 
strongly recommends bichlorid of mercury i-i6th of a grain 
three times a day, which is often of great value, but some prefer 
the biniodid; their action is probably identical. Tilbury Fox 
advocated diuretics, followed by the mineral acids and nux 
vomica. I have used this plan a good deal, but latterly have 
found the salicin treatment gr. xv to gr. xx ter die of great 
value in a large proportion of subacute cases, and have suc- 
ceeded without local treatment in producing involution in many 
instances. Where the patches are few, indolent, and chronic, 
and in most hypertrophic and verrucose cases, internal treat- 
ment is of little avail, but an extensive hypertrophic eruption 



442 DISEASES OF THE SKIN. 

on the leg in one of my cases entirely disappeared after a 
course of Marienbad taken for gouty conditions. 

In acute, widely spread cases, large doses of quinine in an 
effervescing mixture, as in pityriasis rubra, have succeeded 
well in my hands. Salicin has succeeded in these cases also. 
When the itching is a strong feature, either in acute or chronic 
cases, antipyrin gr. v twice or thrice a day is often most valu- 
able, both in relieving the itching and in calming the patient, 
who too often has but little resisting power left in his shattered 
nervous system. Freeman had success with ammonol in 3 to 
5 grain doses. 

External treatment will materially influence the duration of 
the eruption. Some form of tar is generally useful, but it is 
recommended with reservations. It is very likely to disagree 
where there is intense hyperemia, as such cases will not tolerate 
skin stimulants; here calamin lotion or liniment or inunction of 
oil or vaselin, with a little liquor plumbi subacetatis, or other 
soothing applications, like those referred to in the treatment of 
acute eczema, give most relief. The inunction of olive oil, with 
acid, carbolic, gr. 10, or thymol gr. 10, or ol. rusci TTtx to 5j> is 
often very serviceable in relieving the itching. In nearly all 
other cases some form of tar is very beneficial. As a rule, I 
prefer liquor carbonis detergentis TTLx up to 3j, to one ounce of 
water or calamin lotion, dabbed on several times a day; thymol 
or naphthol gr. 10 to 5ij to 5J of lard or vaselin, or as a lotion, 
have been found very useful. Where strong remedies can be 
borne, nothing, in my opinion, acts so quickly as the soap and 
spirit liniment with 5ss to oiv of oil of cade to the ounce. As a 
rule, the best plan is to begin with a weak application and 
gradually to increase the strength. Other remedies recom- 
mended are salicylic acid or bichlorid of mercury lotion. 
Unna's formula of gr. 20 of carbolic acid and gr. 2 to 5 of hyd. 
bichlor. to the *j of zinc ointment has often been serviceable in 
my hands; ol. rusci Tr^xx, ung. hydrarg. ammon. §j, is another 
useful formula. Alkaline and bran baths are likely to do good 
in almost all cases, and tar or sulphur baths sometimes. 
Jacquet strongly recommends hydrotherapy in the form of 
gentle tepid douches for several minutes, to be followed by mo- 
mentary cold ones. The verrucose patches are very rebellious 
to treatment. Unna's salicylic plaster, applied until the hard- 



LICHEN VARIEGATUS. 443 

ened epidermis can be removed, is a useful preliminary. Then 
the pure oil of cade should be brushed in, and a solution of 
bicarbonate of soda, 5ij to the pint, applied on lint under oiled 
silk. Or the Beiersdorf paraplast of mercury 50 per cent., 
carbolic acid 7.5, may be applied after the salicylic acid plaster 
has done its work. It has been recommended to lightly stroke 
the patch with Paquelin's cautery, and then apply boric or 
other mild antiseptic ointment; but this is rarely necessary, and 
few patients would consent to it, as the patches give very little 
inconvenience except itching. Time alone removes the pig- 
mentation left after the removal of the papules or patches. 



LICHEN VARIEGATUS.* 

Synonyms. — Parakeratosis variegata (Unna), Dermatitis varie- 
gata (Boeck), Psoriasiform and Lichenoid Exanthem 
(Neisser, Jadassohn, Juliusberg, and F. Pinkus), Erythro- 
dermie pityriasique en plaques (Brocq), Pityriasis Lichen- 
oides Chronica (Juliusberg), Dermatitis psoriasiformis 
nodularis. 

Unna and his pupils, Santi and Pollitzer, were the first in 
1890 to differentiate this rare form of disease, although cases 
had been previously recorded as a variety of lichen planus, etc. 
Since then cases have been published by Neisser, Jadassohn, 
Juliusberg (three cases), Pinkus, Rona, etc., but Unna's name 

* Literature.— Tilbury Fox's Atlas, Plate XIII., called Lichen Ruber, 
from a St. Louis model of a case of Lailler's; a copy of it is in the College 
of Surgeons Museum, No. 88, Derm, series, labeled by Erasmus Wilson 
Lichen Planus— var. Retiformis. Parakeratosis variegata: Unna, Santi, 
and Pollitzer, Monatsh. f. ftrak. Derm., vol. x., Nos. 9 and 10. 1890, 
with a general review of the class they called parakeratosis, give the 
history of two cases. Psoriasiform and Lichenoid Exanthem: Jadassohn 
in Verhandl. IV., Deutschen dermat. Congr., Juliusberg, Archiv f. 
Derm. u. Syph., vol. xli. (1897), p. 256, and under the title, Pityriasis 
Lichenoides Chronica, loc. cit., vol. 1., Heft 3, 1899. F - Pinkus in Pick's 
Festschrift, 1898; Brocq, " Erythrodermies Pityriasiques en plaques dis- 
seminees," Revue Generate de Clin, et de Tkerap., 1897. Fox and Mac- 
leod on a case of Parakeratosis Variegata, Brit. four. Derm., vol. xiii. 
(1901), p. 319, with histology and abs., with critical review of nearly all 
the cases to date. Abraham has shown a case since their paper, a 
woman, set. twenty-two. 



444 DISEASES OF THE SKIN. 

has not met with acceptance, so I venture to propose it as a 
form of lichen,* the clinical resemblance to lichen planus having 
been recognized by most observers. Jamieson in 1898 showed 
three cases in Edinburgh, and Eddowes one in London in 1899; 
Colcott Fox showed a case, and I have shown two cases to the 
Dermatological Society of London. The eruption is general 
in distribution, sometimes including the face, of slow evolution 
and very chronic course, lasting for years (thirty years in a 
case of Jamieson's). Subjective symptoms are as a rule almost 
absent, though in Brocq's case itching preceded the eruption 
and subsided when it was out, and in mine it itched at night, 
and if he began to scratch he could not leave off. The most 
striking feature is the arrangement in bands or semi-confluent 
patches, oval or round, inclosing areas of healthy skin, so that 
a reticular appearance is produced. The patches are covered 
with thin, delicate scales, which, on removal, leave the skin 
shiny or waxy-looking, and of a yellowish or bluish tint, the 
color being deeper on the lower extremities. The eruption as 
a whole has a pale lilac hue. There is a slight atrophy left for 
a time, where papules have involuted. 

The patches are generally well defined, and while the smaller 
resemble lichen planus, the larger are erythematous, rough or 
rather scaly, and decidedly infiltrated. There are also dis- 
seminated very flat pin's-head to lentil-sized papules with 
usually a small scale in the center, and there is sometimes 
bleeding on removal. This is the early or lichen stage; the 
scaly or psoriasiform stage is a later development. 

Variations. — All the cases previously referred to, described 
under various names, have a general resemblance clinically, and 
a still closer one microscopically. In all subjective symptoms 
were almost absent, and all were unaffected by local applica- 
tions, and had a similar regional distribution. They presented 
some minor differences. In Brocq's erythrodermie pity- 
riasique there were disseminated plaques instead of reticulation. 

* Fox and Macleod object to the generic title " Lichen," because the 
primary lesion cannot always be proved to be a papule; but it is only 
meant as a convenient clinical term, and designates a conspicuous 
feature of all well-marked cases which has struck every describer, and it 
avoids the erroneous term parakeratosis. Jamieson strongly upholds 
that the disease is a lichen. 



LICHEX VARIEGATUS. 445 

J. C. White referred his cases to Brocq's type, but his second 
case was like one of mine. In Jadassohn's psoriasiform and 
lichenoid exanthem the papules were not reticular, but were 
grouped, oval or round, had fine scales, and bled easily when 
these were scratched off. 

In the seven cases collected by Juliusberg the primary lesion 
was a smooth, red, flat, pin's-head-sized papule like that of 
lichen planus, which subsequently acquired a thin, shining white 
scale. 

They are all evidently only variants of one affection, the ar- 
rangement of the exanthem being the most variable feature. 

Etiology. — Neither age nor condition seems to have any bear- 
ing on the disease, but it is much more common in men than 
women. One case (Juliusberg) began at seven years, the 
others have begun in adult life. Pinkus' case and my own were 
worse in winter, but the others have been unaffected by season. 
Being subjected to great and sudden variations of temperature 
seemed to have an etiological bearing in some cases. 

Patlwlogy. — This is unknown. Fox and Macleod's sugges- 
tion, that it is due to a vaso-motor disturbance associated with 
edema and infiltration of cells in the corium, with secondary 
changes in the epidermis, appears to fit the facts. 

Anatomically there are slight inflammatory changes with cell infiltra- 
tion in the papillary layer and slight increase in the prickle cell and 
horny layers. Unna regards these changes in the epidermis as primary, 
hence his term parakeratosis, but this cannot be proved. Juliusberg 
admits the similarity of histology of his cases to Unna's, but thinks they 
are different diseases. Macleod showed sections to the Dermatological 
Society of London, in which there was no parakeratosis to signify, and 
in some parts, actual thinning of the epidermis. The granular layer was 
either diminished, absent, or well-defined. The general result was that 
of a superficial inflammation of the corium, with secondary changes in 
the epidermis. 

Diagnosis. — The slow evolution, persistent generalization, 
absence of itching, reticular or patchy arrangement, papulo- 
scaly and scaly patch aspect, persistence, and rebelliousness to 
treatment, are the most distinctive features. The absence of 
scaly crusts, only delicate scales, the general arrangement and 
whole picture, are different from psoriasis. It is most like 
lichen planus, but the scaly character, even in the papular stage, 
the reticular arrangement, the rebelliousness to treatment, 



446 DISEASES OF THE SKIN. 

together with the frequent involvement of the face and the ab- 
sence of itching, are differentiating characters. The attempt of 
some authors to distinguish between the parakeratosis varie- 
gata of Unna and psoriasiform and lichenoid exanthem 01 
Neisser, etc., is, in my opinion, futile, the more scaly cases 
being of longer duration than the others. It is also like the 
lichenoid premycosis erythrodermia. One of Jamieson's cases 
claimed by Unna as parakeratosis variegata turned out to be 
mycosis fungoides. 

Treatment. — All concur in its being most rebellious to treat- 
ment both internal and external. Unna claims most success 
with frictions with pyrogallic acid so strong as to be dangerous 
but for the administration of large doses of hydrochloric acid, 
which neutralizes its poisonous effect. Chrysarobin externally 
and arsenic internallv have failed to touch the disease.* 



LICHEN SCROFULOSUS.f 

Synonym. — Lichen scrofulosorum. 

Definition. — Lichen scrofulosus is characterized by very small 
chronic inflammatory papules, of a red color, fading to that of 
the normal skin, disposed in groups and circles, and occurring 
mainly in scrofulous subjects. 

Mild degrees of this eruption are not uncommon among the 
children of the poor, but are usually only discovered accident- 
ally, but although commoner than supposed, well-marked cases 
are rare. Neumann reckons it at 3 per 1000 cases of skin diseases 
in adults, and 5 per 1000 in children, and my own experience 
at the East London Hospital for Children gave the same pro- 
compare Plate XXVI. of Author's Atlas, representing a remarkable case 
named psoriasis follicularis; although psoriasiform, lichenoid, and reticu- 
lar, both the eruption and the general history were different from lichen 
variegatus. 

f Illustrated in Author's Atlas, Plate XXXIV., Fig. r. on the leg of a 
child. Hebra's Atlas, Lief. 9, iii., Plate III., trunk and arms. The small 
follicular syphilid in the syphilid plate of this work would equally well 
represent this eruption, except that it is of slightly browner hue. Twenty- 
one cases, including fifteen of my own and six of Dr. Tilbury Fox, were 
published in vol. xii. of the Clin. Soc. Transactions, in which there is a 
very good plate of the disease. 



LICHEN SCROFULOSUS. 447 

portion, while at U. C. H., with cases at all ages, only half that 
proportion are met with. 

Symptoms. — The papules in this disease are from a pin's point 
to a pin's head in size, slightly conical, of a bright red at the 
very first, fading later into a pale red or fawn color, or even the 
color of the normal skin, and tending to be arranged in round- 
ish groups, circles, or segments of circles, i. e., the normal ar- 
rangement of the hair follicles; other papules may, however, 
appear in the intervals of the groups in some parts, filling them 
up, and so producing large surfaces covered with the eruption, 
and looking very like an exaggerated cutis anserina. A 
minute scale is formed upon each of the older papules, which, 
after remaining for a variable period of weeks or months, 
undergo retrogression, desquamate, and leave behind them 
small yellowish pigmented spots. 

The eruption is usually limited to the trunk, itching is absent 
or very slight, and some evidence of tuberculosis is nearly al- 
ways present. 

With regard to position, it is usually more abundant at the 
sides of the trunk and over the lower ribs and flanks, than upon 
the front and back; the neck is often affected, the limbs rarely 
beyond the groins and axillae, but when they are, the arms are 
more frequently involved than the legs. In one of Neumann's 
cases, aet. four and a half years, the whole surface was affected, 
except the legs. The papules may be grouped round lesions of 
scrofuloderma or lupus. 

Course. — Fresh papules frequently form elsewhere, and thus 
by successive crops keep up the disease for years, or the dis- 
ease disappears for a time and then recurs. It leaves no scars 
in its train. 

Variations and Complications. — In addition to the above-de- 
scribed papules others of a larger size may be seen here and 
there with a yellow sebaceous plug in the center, which may 
go on to form acne pimples or pustules. These pustules may 
also arise even where there are no other papules, as on the 
limbs or face. An extreme development without any lichen 
scrofulosorum is described under Acne. 

In some cases many of the papules have a horny spine pro- 
jecting from their center, the condition called lichen spinulosus 
being present as a complication. 



448 DISEASES OF THE SKIN. 

Hallopeau has observed papules like those of lichen acumi- 
natus on the back of the first phalanges of the fingers. In 
severe cases fine branny, glistening scales are formed between 
the papules, giving the skin a very cachectic appearance. These 
lesions are really only a special feature of the disease, but other 
concomitant skin affections may occur, such as seborrhea of 
the scalp (Neumann), purpuric extravasations into the hair 
follicles, especially on the dorsum of the feet, which is the so- 
called " lichen lividus," and, more common than this, a pus- 
tular eruption about the genitals of an eczematous nature, be- 
ginning as inflammatory nodules. 

Undue prominence of the hair follicles was noticed by Dr. 
Tilbury Fox to be generally present. 

According to German authorities 90 per cent, have some 
evidence of scrofula in the shape of enlarged lymphatic glands, 
especially the cervical, submaxillary, axillary, and tonsils; caries 
or other bone-lesions and ulceration of the skin are also com- 
mon. Lupus vulgaris was present in six out of forty-three 
cases of Lukasiewicz. Phthisis is unusual, but may be present, 
and frequently figures in the family history, and several of my 
cases had pleuritic effusion; on the other hand, I have met with 
one case where the child was well nourished and apparently in 
perfect health, with a good family history; nevertheless, cod- 
liver oil cured her. 

Children. — The limbs are more frequently affected in children 
than in adults, and the eruption may occur there without in- 
volving the trunk, a peculiarity hardly ever seen in adults,* and, 
as far as my experience goes, the younger the child the less the 
liability to acne pustules. Phthisis also is a more common ac- 
companiment in children than in adults. 

Etiology. — The scrofulous predisposition seems to be the 
main, if not the sole cause; though, according to Lukasiewicz, 
insufficient food or any drain on the system may lead to it. 

Age. — The disease is commonest in childhood; Neumann's, 
Kaposi's, and the English cases agree in this; yet Hebra's 
original description was taken from over fifty consecutive cases 
which were all between fifteen and twenty-five years, probably 
from there being only a small proportion of children in his clinic; 

* In a woman of twenty-one under Lukasiewicz, the lower extremities 
alone were the site of a thick eruption. 



LICHEN SCROFULOSUS. 



449 



but the vast majority of cases occur between two and twenty 
years. 

The youngest case I know of was one of my own, set. eleven 
months; the oldest a case of Lukasiewicz, set. fifty-six years. 

Sex. — It is much more common in males, at least in Ger- 
many, for all Hebra's cases and thirty-five out of forty-three of 
Lukasiewicz's cases were males. On the other hand, a ma- 
jority of the English cases were females. 

Anatomy.— Kaposi's investigations in 1868 showed "that the lichen 
papule is formed by a cell infiltration of the papillae around the follicle, 
and the central scale, by a collection of epidermis at its dilated orifice." 
These exudation cells are first seen round the vessels and in the meshes 
of the areolar tissue at the fundus of the follicle and sebaceous glands, 
and later, within those structures, afterwards accumulating to such an 
extent in their interior that the sebaceous gland-cells are thrust toward 
the aperture, and the root-sheath separated by the follicular wall, which 
becomes quite distended by the accumulated cell-mass. More recent 
observations do not invalidate the above. 

Darier found also perifollicular changes, which appeared to him to be of 
a tubercular character; giant cells surrounded by numerous nuclei were 
conspicuous. Jacobi and Wolff found bacilli, and from another case 
Jacobi made intra-abdominal inoculations with papules into a guinea- 
pig, and found caseation of mesenteric glands near the points of inocula- 
tion. On the other hand, Jadassohn and Lukasiewicz failed in similar 
experiments, as did also Lafitte from a case of Hallopeau's, and Lefebre 
had a negative result, but Pellizarri succeeded; and in 1899 Haushalter * 
inoculated four guinea-pigs with scrapings of L. scrofulosus with posi- 
tive results; but his diagnosis is not indisputable, as the eruption was 
scattered, left scars, and involved the face. Wolff also has found bacilli. 
Lukasiewicz f examined twelve cases histologically, and although he 
found giant cells there were neither tubercle bacilli nor caseation nor 
coagulation necrosis, and he considered, therefore, that there was no 
ground for regarding it as a tuberculous morbid process. He says there 
is an infiltration of large fusiform cells, beginning round the sebaceous 
glands and extending to the hair and sweat follicles,:}: and regards the 
whole process as due to malnutrition, of which tuberculosis is only one 
cause. He thinks Sack's observations were made on the miliary syphilid, 
which so closely resembles L. scrofulosus. 

The clinical behavior of the disease is so unlike any indisputable 
tuberculosis of the skin due to the direct presence of tubercle bacilli that 

* Haushalter, Amiales de Derm., etc., vol. ix. (1898), p. 455. 
\ Archiv fur Derm. tc. Syph., vol. xxvi. (1894), p. 33. Full abs. Brit. 
Jour. Derm.; vol. vi. (1894), p. 314. 

\ In a case of Hallopeau's also the sweat glands were involved. 
29 



45 o DISEASES OF THE SKIN. 

further demonstration of their presence will be needed, before it can be 
accepted as a direct tuberculosis. 

Hallopeau's theory that it is due to a tuberculin toxin would be much 
weakened by Jadassohn's observations of a case in which the eruption 
disappeared under the influence of tuberculin injections ; but, on the 
other hand, Schweninger and Buzzi state that they have seen it develop 
after tuberculin injections. A possible explanation of the discrepancy of 
the experiments is suggested by Gilchrist's * observation that there were 
typical tubercles in the deep part of the skin below the hair follicle from 
a negro child, while the anatomical process producing the papules them- 
selves was quite superficial. Thus, while the papules themselves may 
not be directly tubercular, they may have been produced by the more 
deeply seated tubercle itself. 

Diagnosis. — The small size and pale red color of the papules, 
their arrangement in groups and circles, their limitation to the 
trunk, and the youth of the patient, together with the absence 
of itching f are the most distinguishing features. The diseases 
most resembling it are papular eczema, follicular syphilids, L. 
pilaris, and occasionally psoriasis punctata. It has no relation 
whatever to L. circinatus. 

Papular eczema is not so likely to be limited to the trunk, the 
papules are a brighter red, some of them are very likely to go 
on to vesiculation at their summits, and itching is almost al- 
ways a prominent symptom, and there is not the same group- 
ing in clumps and circles. 

The large and more common of the follicular syphilids has, in 
comparison with L. scrofulosus, much larger papules, of a 
deeper, duller red, the limbs are more often affected, and there 
is sure to be confirmatory evidence of syphilis, as it occurs 
rather early in the secondary period. The small follicular 
syphilid is rare, and, as far as the papules and groups are con- 
cerned, identical in appearance with L. scrofulosus, \ but the 
limbs and even scalp may be affected, and though I have seen 
it in a girl of eleven years, generally the age of the patient will 
suggest further investigation, when other evidence of syphilis 
will be almost surely forthcoming. 

* Reprint from Johns Hopkins Bulletin, No. 98, May, 1899. 

f Though usual, it is not invariable, and I have known it very marked 
in the early stage. 

% In two well-marked cases, both women over forty, the resemblance 
was so exact that it was only these points that gave me a 'clew to their 
real nature and led to the discovery of conclusive evidence of syphilis. 






LICHEN SCROFULOSUS. 451 

Where the scaliness (so often present in a moderate degree) 
is unusually abundant, and masks to some extent the typical 
character of the eruption, L. scrofulosus may be mistaken for 
psoriasis punctata. Its limitation to the trunk, the absence of 
itching, together with the fact that each papule does not enlarge, 
and that, as confusion will only occur in severe cases, there are 
sure to be sebaceous plugs in some of the papules, if not actual 
acne pustules, will distinguish the lichen, while other evi- 
dence of scrofula is sure to be strong in such cases. 

The true inflammatory lichen pilaris is distinguished by the 
groups being few in number in most cases. The papules are 
larger and generally limited to the limbs, and contain spiny 
plugs of epidermis. When this condition complicates lichen 
scrofulosus, the spines spring from the papules of L. scrofulo- 
sus, which are smaller than those of L pilaris; moreover, there 
are sure to be groups in which there are no spines, and the whole 
picture would be that of L. scrofulosus, not of L. pilaris. 

Prognosis. — The disease is always curable ; and even untreated 
cases, though perhaps lasting intermittently or persistently for 
years, do not produce much inconvenience. 

Treatment. — This is simple and effectual. Cod-liver oil, inter- 
nally and externally, always removes the eruption. It should be 
given in moderate doses at first, increased up to as much as the 
patient can assimilate; i. e., rarely more than half an ounce a day 
for a child of five, and an ounce and a half a day for an adult. 
Externally it must be not only rubbed in, but the skin kept con- 
stantly soaked with it. This is Hebra's treatment, and answers 
well, but is, necessarily, extremely disagreeable for all parties 
concerned. I have, therefore, tried other emollients, and have 
found that the inunction of vaselin, either plain, or better with 
liq. plumb, subacetatis TIXxv, thymoli gr. 5, or ol. cadini TTLv, to 
the ounce, is quite as effectual and much more pleasant, while 
smaller doses of oil are usually sufficient, and less likely to upset 
the patient. 

Chrysarobin gr. v to gj has been recommended as very effica- 
cious, but its staining quality and tendency to produce erythema 
restrict its use to obstinate cases of limited extent. 



452 DISEASES OF THE SKIN. 

LICHEN PILARIS SEU SPINULOSUS.* 

Synonym. — Lichen spinulosus (Devergie). 

Definition. — An inflammatory disease of the hair follicles, in 
which a spiny epidermic peg occupies the center of the papule. 

The term L. pilaris was formerly used for the affection de- 
scribed elsewhere as keratosis pilaris; it is here employed, in 
conformity with the other lichens, for an inflammatory eruption. 
It is rather a rare disease. Numerous cases, mostly in chil- 
dren, have come under my observation. 

It may develop acutely or subacutely in crops, and consists of 
papules about the size of a pin's head, red, conical, and contain- 
ing in their center a horny spine, seen, when viewed obliquely, 
to project about one-sixteenth of an inch, and when the hand is 
passed over the affected region, it imparts to it the sensation of 
a nutmeg-grater ; this epidermic plug can be picked out, leaving 
a depression in the papule. When the papule has been present 
some time the redness subsides, and the papule is the color of 
the normal skin. There is little or no itching, and the eruption 
gives but trifling inconvenience, except from the discomfort pro- 
duced by the horny spines catching in the clothing. 

The papules are densely crowded into patches, often very large 
and irregular in outline, symmetrically distributed, sometimes 
in a few, sometimes in many regions of the body. The positions 
most common are the back of the neck, the buttocks, the tro- 
chanteric regions, the abdomen, the back of the thighs, the popli- 
teal spaces, and the extensor aspect of the arms. There are few 
parts of the body exempt, but I have never seen it on the face,, 
upper part of the chest, the hands, or the feet. I have seen it 
en nappe from the hair line to the loins, but in these extensive 
cases the horny spines vary much in development, the longest 
being generally on the neck. 

Where the eruption is not so dense there is a tendency to 
form roundish groups, and there are always some disseminate 
papules, besides those in the main patches. The eruption comes 

* Illustrated in Author's Atlas, Plate XXXIV., Figs. 2 and 3, an unusu- 
ally extensive case on the trunk and thighs of a youth, set. sixteen, some- 
what older than the majority of cases. It is a disease difficult to depict 
in a drawing. 



LICHEN PILARIS SEU SPINULOSUS. 453 

out in crops, a patch appearing perhaps in the night, and con- 
tinuing to increase for a week by the development of fresh pap- 
ules. After this, except that the papules grow paler, there may 
be no change for an indefinite time. As a rule, this eruption is 
the only one present, but I have seen it associated with L. 
scrofulosus, the small follicular syphilid, and also with L. 
planus. 

In these cases the original disease retains its characters with 
the addition of horny spines in the center of the papules, so 
that it is not quite correct to say that lichen pilaris is mixed 
with these other diseases. 

Etiology. — The cases are too few in number, and the litera- 
ture is too scanty, to afford much material for ascertaining its 
causation. In my experience it has occurred chiefly in children, 
and more often in boys than girls. The most extensively af- 
fected case was a boy of fifteen, whose father suffered from 
psoriasis; I have also seen it in a woman over thirty. Several of 
the patients nave been pale and delicate-looking, but there has 
been no very definite ill-health. 

Pathology. — There is evidently first congestion of the vessels, 
followed by slight effusion round the follicle, and hyperplasia of 
the epidermic cells lining it. The occurrence of spines as a com- 
plication or sequel of other papular eruptions shows that more 
than one kind of inflammation may give rise to the affection. I 
am not aware of any histological investigation of this form of 
folliculitis. Unna's observations refer to keratosis pilaris, or 
suprafollicularis, as he calls it. 

Diagnosis. — This presents no difficulty. Keratosis pilaris is 
the most like it, especially when the redness of the lichen has 
subsided; but though keratosis has an epidermic plug, it is not 
spiny like that of L. pilaris, develops very slowly, and there is 
no inflammatory redness at any period; it is also a diffuse, not a 
patchy eruption, and when the epidermic plug is picked out, the 
whole lesion is removed. 

Lichen acuminatus also has some points of resemblance, but 
it is a diffuse general eruption; attacks the hands, which escape 
in L. pilaris, and the epidermic plug is scaly, not spiny. The 
primary papules of lichen verrucosus which may accompany 
lichen planus have been confused with this affection, as the 
papules are acuminate or conical with central horny projections, 



454 



DISEASES OF THE SKIN. 



but they have not the spiny character of L. pilaris; the papules 
tend to coalesce into warty masses with a dirty green horny 
surface, and ordinary lichen planus papules are nearly always 
to be found in some part of the body. 

Prognosis. — It is always amenable to treatment, but will, if left 
to itself, last for an indefinite time. 

Treatment. — Alkaline baths and friction with the hand while in 
the bath are useful preliminary measures, and then a liniment of 




Fig. 26. — Lichen pilaris (special variety). 

b, orifice of the hair follicle filled up with horny cells ; c, cells of the rete, 
elongated by the pressure upwards of the inflammatory effusion of 
leukocytes and serum as shown at a , d, artery with the end lost in a 
mass of leukocytes. 



soft soap and spirit of wine with a dram of oil of cade to the 
ounce, rubbed in with a piece of moistened flannel, has been per- 
fectly successful in my hands. Internally, cod-liver oil, iron, 



LICHEN PILARIS SEU SPINULOSUS. 455 

and general invigorating measures are indicated in most cases. 
If the redness is marked, the inunction of oil after the baths, in- 
stead of the soap liniment, would be advisable at first. If there 
are only one or two patches, a weak Beiersdorf salicylic acid 
and creasote plaster would be a good application. 

Besides the above affection there is a disease of the hair folli- 
cles, of which I have seen a few examples, truly inflammatory in 
my opinion, which may be thought to be as fairly entitled to the 
designation as the first one, but it is an uncommon and not 
very important affection. 

Symptoms. — Firm, pale red papules, with a small collection of 
minute scales in the middle, the center of each papule being 
pierced by a hair, are arranged in irregularly circumscribed 
patches upon the extensor surfaces of the limbs, or occasionally 
on the flanks. The patches are few in number and feel rough to 
the touch, but not so much so as in the preceding affection. 
They may remain for many months, or even years, untreated. 
There is moderate itching and no special defect of health. I 
have seen it only in young adults. 

In a case which was under treatment for psoriasis irregularly 
circumscribed patches of papules, like those just described, ap- 
peared symmetrically on the backs of the hands and fronts of the 
thighs where there had been no previous psoriasis. This is a 
very rare occurrence and suggests the possibility that the ap- 
parently primary affection is really a psoriasis pilaris. 

Anatomy. — In a piece of skin excised from the thigh of this case 
I found cell effusion into the angles formed between the follicle and 
rete, greatest above, but extending in a minor degree nearly to the 
bottom of the follicle. The cells of the rete at the angle were elongated, 
and the whole layer adjacent to the follicle thickened, while there was 
considerable accumulation of horny cells at the mouth of the follicle, 
some adherent to the hair shaft, producing the funnel-shaped condition 
seen in keratosis pilaris ; in short, it is a keratosis pilaris plus inflamma- 
tory effusion round the follicle (Fig. 20). 

Treatment is the same as that for the first-described L. pilaris. 

Under the head of L. pilaris some authorities, like Tilbury 
Fox, include inflammatory conditions of the hair follicles, secon- 
dary to chronic scabies or other diseases, producing irritation 
where the firm papules, with no central scales, are scattered over 
the trunk and limbs, but no designation is required for such a 
purely symptomatic condition. 



456 DISEASES OF THE SKIN. 

LICHEN ANNULARIS (Galloway).* 

This is a very rare eruption, of which there are only two in- 
disputable cases on record. 

In 1895 Colcott Fox showed at the Dermatological Society of 
London a ringed eruption on the fingers of a girl of eleven 
which had existed for two months ; and a boy of ten was shown 
in 1898 by Galloway, in whom the disease had been present three 
years. These two cases were undoubtedly of the same char- 
acter, and the eruption was limited to the sides and back of the 
fingers and thumbs, except that in Galloway's case a single 
nodule was present in one ear. 

The lesions began as a nodule, which' extended peripherally 
into a circular patch, and then into a round or oval ring by clear- 
ing pari passu in the center, where the skin became normal again 
or faintly atrophic; the border, an eighth of an inch wide, was 
smooth, rounded, projected the sixteenth of an inch above the 
surface, was of an ivory-white color and doughy consistence ac- 
cording to Fox, while Galloway described the border as hard. 
In Galloway's case there was a small common wart on the right 
third finger. 

Dubreuilh in 1895 published a case which he considered to 
be of the same character in a woman of thirty-three with a bad 
circulation. The lesions were firm pale elevations on the radial 
border of the two index fingers, and on the ulnar border of the 
left thumb. They began five years previously, and slowly in- 
creased. The ring was pale, elevated a millimeter, slightly scaly, 
and firm to the touch. It was cured with Vidal's red plaster, but 
recurred five years later. 

In Fox's case no etiological factor could be detected, while 
Galloway's was a delicate-looking boy who had gone through 
the gamut of children's diseases, and there was also the wart 
previously mentioned, which might possibly have some signifi- 
cance. There was no history of rheumatism either in the patient 
or the family in either case. Galloway's histological examination 
showed that the process was " a chronic inflammation of the 

*" Lichen Annularis," by J. Galloway, Brit. Jour. Derm., vol. xi. 
(1899), p. 221, with colored and microscopic plate, and abstracts and ref- 
erences to Colcott Fox's case and various others more or less resembling 
it. Compare with Granuloma Annulare. 



DERMATITIS. 



457 



upper layers of the cutis associated with the increase in the over- 
lying epithelium " ; " the nature and distribution of the inflam- 
matory infiltration resembled closely that of lichen planus — and 
although there were very wide clinical differences between the 
two diseases, the histological characters bring the lesion within 
the most strict definition of the term lichen." 

The treatment adopted by Galloway was the application of a 
two to ten per cent, salicylic acid ointment, the administration 
of iron and cod-liver oil, and improved hygiene. With these the 
lesions gradually underwent involution, and in six months had 
disappeared, and the boy's health had much improved. 

DERMATITIS. 

There remain to be considered certain inflammations of the 
skin which have no special name, their peculiarities arising, not 
from the form and arrangement of the elementary lesions, but 
from their cause. Some of these causes exert their effect di- 
rectly, i. e., from external application, others indirectly, i. e., when 
taken internally; and while they are classed, for the sake of 
convenience, under the name of dermatitis, and some qualifying 
term is added pointing to their origin, they have often but little 
in common, except their general title. The predominant lesion 
in the greater number of them is some form of erythema, but all 
of the elementary lesions may be excited, according to the sus- 
ceptibility of the individual to the particular influence, its inten- 
sity, and the length of time it is in operation. The signs of in- 
flammation — heat, redness, and swelling — are in proportion to 
the severity of the lesion. The several groups will be considered 
under the heads of D. traumatica, D. calorica, X-ray Dermatitis, 
D. venenata, D. medicamentosa, D. vacciniata, D. gangrenosa. 

D. Traumatica. Under this head are included all kinds of in- 
flammation set up by mechanical causes, such as contusions, 
abrasions, or excoriations, whether due to blows, pressure, fric- 
tion (c. g., from riding, rowing, clothing faulty in construction 
or material), or scratching to relieve the irritation set up by 
animal parasites, scabies, pediculosis, etc. The excoriations 
from scratching are often the most important to the derma- 
tologist, and have already been described when considering the 



458 DISEASES OF THE SKIN. 

pruritic or " scratched skin." The other lesions are so well 
known, even to the laity, as not to need detailed description. 

D. Calorica. Extremes of heat and cold are almost equally 
capable of producing more or less severe inflammation of the 
skin, according to their intensity and length of time of the ap- 
plication. Erythema solare, or sunburn, is a familiar example 
of what may be produced by natural heat, and while it may be 
erythematous, vesicular, or bullous, it never goes on to com- 
plete destruction, as it may do from artificial or ordinary burns 
or scalds. Bowles,* however, has shown that it is not the heat 
rays, in all probability, but the ultra-violet or chemical rays 
which produce such violent inflammation, and, as is familiar to 
every climber, the reflection of those rays from snow consider- 
ably aggravates their effects; further, that red and yellow 
pigments stop these irritant rays; merely greasing the skin be- 
fore exposure will also prevent sunburn, though not so com- 
pletely as the pigments. Cold may also produce death of the 
part from prolonged anemia, or from too sudden reaction and 
consequent destructive inflammation. 

X-ray Dermatitis. Exposure to the Rontgen rays when 
unduly prolonged, or too frequently used at short intervals, 
especially with soft tubes, is liable to set up a dermatitis which 
in slight cases only reaches to erythema followed by pigmenta- 
tion, but is in some cases so severe as to destroy the vitality of 
the exposed part, and lead to the production of a dry superficial 
slough, which takes months to separate, and may leave an 
ulcer which takes months or even years to heal. Such cases 
were frequent in the early days of X-ray employment (Gil- 
christ collected twenty-eight cases), but are less frequent now. 
Several cases have come under my observation. One of them 
of moderate severity, after three exposures of an hour on the 
abdomen, was a hand-sized dermatitis, of which the central por- 
tion ulcerated and took four months to heal. In another case 
an adherent black dry slough, seven by five inches, was firmly 

* " The Influence of Light on the Skin," etc. An introduction to a dis- 
cussion at the Dermatological Society of Great Britain and Ireland in 
May, 1897. Transactions of the Society, vol. iii. (1897), and references to 
previous communications. 



DERMATITIS. 459 

adherent nine months after two exposures of forty and ninety 
minutes respectively. In a third, four years after an attempt 
to radiograph the kidney, there were still ulcers of about an 
inch in diameter unhealed, while the rest of the hand-sized burn 
had cicatrized, leaving a closely meshed scarlet network of 
dilated capillaries all over the cicatrized area. In two other 
cases of X-ray burn I have seen a similar telangiectic network 
in the cicatrix, so it is probably a diagnostic feature. In a 
third case the same phenomena were present, though there 
had never been active inflammation. It is emphatically a mis- 
fortune that it is better to prevent than to cure, but while in 
most cases it may be prevented by being careful not to subject 
the patient to exposures with the tube in too close proximity or 
of too long duration or frequency, there is no doubt that, be- 
sides the quality of the tube, idiosyncrasy plays a part, and that 
a dermatitis may be set up in some persons by an exposure or 
exposures which would not do so in others. Moreover, in 
using the X-rays for therapeutic purposes, where repeated ex- 
posures have to be made and a slight amount of dermatitis is 
sometimes desirable, although the treatment may be left off as 
soon as erythema appears, the inflammation increases in in- 
tensity, sometimes for a week or more, going on to vesicula- 
tion, ulceration, and even sloughing, to the embarrassment 
and chagrin of both patient and operator. 

According to Unna, in these cases the collagen (connective 
tissue) may be mainly affected. It becomes more brittle, and 
its staining reactions are basophile instead of acidophile, as it 
is when normal. Possibly this is the reason for the slow heal- 
ing. In Gilchrist's case osteorathritis occurred. Experi- 
menters whose hands are constantly exposed to the rays, in ad- 
dition to erythema, sometimes shed the nails and hairs, but not 
permanently, unless they persist in the exposures. It has been 
suggested by Bowles and others that the effects of the X-rays 
are analogous to those of sunburn aggravated by the proximity 
of the lamp and the frequent repetition of the exposures. 

Treatment. — Slight degrees of inflammation may best be 
treated by the frequent application of calamin lotion. More 
severe inflammations with exudation are best treated with 
lactate of lead lotion constantly applied, which subdues inflam- 
mation and heals superficial ulceration. Deep ulcerations may 



4 6o DISEASES OF THE SKIN. 

be treated on ordinary surgical principles, but give great 
trouble, and if the size and situation permit may be advantage- 
ously excised. 

Apostoli cured one case of great severity by the combined 
electric treatment, " i. e., I. the polar application of a galvanic 
current, in order to accelerate the fall of the eschar, and thus 
favor the tropical and ulterior trophic action of the static bath. 

" 2. Simple static bathing, which, by its general influence as 
well as by its direct and local action, hastens the work of repair 
and cicatrization of ulcers. 

" 3. The general action of a current of high frequency, which 
is destined to raise the coefficient of generation nutrition." 

It is obvious that very few patients will be able to get all this, 
but in the case in question, which was of the worst type, heal- 
ing took place under this procedure. 

D. Venenata. This includes the various inflammations set up 
by numerous external irritations of animal, vegetable, or 
mineral origin. The effects produced on the skin are 
erythema, wheals, papules, vesicles, pustules, bullae, or gan- 
grene, according to the susceptibility of the individual, the 
virulence or concentration of the poison, and the length of ex- 
posure to its influence. Eczematous subjects are especially 
sensitive to such irritating influences, and in such persons 
eruptions are not only more easily started and more severe, but 
often persist long after the removal of the cause, in the form of 
an eczema, indistinguishable from ordinary eczemas of sup- 
posed internal origin. 

It is impossible * in this work even to merely enumerate all 
the external irritants, and it will probably be more practically 
useful to give headings which will indicate under what circum- 
stances they occur, and give examples under each. These 
include: 

1. Articles in medicinal use applied externally. 

The commonest are the well-known irritants — mustard, tur- 
pentine, cantharides, tartar emetic ointment, croton oil, 
mezereon, savin, arnica, iodoform, mercury, chrysarobin, 
orthoform, etc. 

* The most complete account is that by J. C. White of Boston, " Derma 
titis Venenata," 1887, and supplementary papers. 



DERMATITIS. 461 

The strong acids or alkalies or other caustics produce, as 
is well known, all degrees of inflammation up to complete de- 
struction of tissue. 

2. Dyes or other substances used in clothing or as cosmetics, 
such as anilin, arsenic, chlorid of tin, chlorid of zinc, and hydro- 
chlorate of paraphenylene diamin (a hair-dye). 

3. Articles used in trades and manufactures, such as bichro- 
mate of potash, aurantia dye, arsenic, etc. 

4. Plant irritants, such as rhus toxicodendron and venenata 
and other species, primula obconica, the common nettle, several 
species of ampelopsis and heracleum giganteum, the flowers of 
doronicum pardalianches, or leopard's bane, cypripedium an- 
gelica, wet ivy, the bulbs of hyacinthus orientalis ascribed 
usually to raphids of oxalate of lime, but Freeman says due to 
an acarus. These are a few of the irritant plants met with in 
England, and White gives a long list which is being continually 
added to from all parts of the world. 

5. Besides the irritant action so well known from the stings 
of bees, wasps, hornets, tarantula, etc., mention may be made 
of the urticarial and even more severe forms of dermatitis pro- 
duced by contact only with jelly-fish and certain caterpillars, 
of which the " woolly bear " * is the chief offender in England; 
on the continent " bombyx processionea " produces more 
serious symptoms, one boy stung by several on the chest hav- 
ing had violent irritation, general sweating, and fever, followed 
by delirium, coma, and death. The long fine hairs which break 
in the skin are said to be the irritants. An Indian species pro- 
duces gangrene. This class need not be further elaborated. 

I. Arnica rashes were very common at one time, when the 
drug was a household remedy for bruises and other slight in- 
juries; but its irritating properties are becoming more generally 
known, and it is deservedly falling into disuse. The com- 
monest form is that of acuminate papules, like the milder form 
of rhus eruption to be presently described. I have known it 
produce an acute vesicular eczema, and in one instance, a pity- 
riasis rubra universalis. 

Chrysarobin. — The external application of this drug is liable 
to produce a peculiar deep, almost coppery red erythema, which 
extends a considerable distance beyond its site of application. 
* Lancet, May 2, 1896, p. 1239, mentions several other species. 



462 DISEASES OF THE SKIN. 

Thus, when applied to a part of the scalp, the whole scalp, face, 
and neck may be affected. There is conjunctivitis, and so 
much swelling that the eyes are closed, and it is liable to be 
mistaken for erysipelas.* In a few days, if the application is 
stopped, and often even when it is persevered with, the redness 
and swelling subside, and a dirty, purplish-brown desquama- 
tion ensues. 

In two cases where I ordered it with lanolin, for alopecia 
areata, there was a copious outbreak of small vesicles also, not 
only on the face, but on the forearms, which presented a very 
eczematous appearance, but soon got well with calamin lotion. 
Brocq f relates that a man died in 1880 in the St. Louis Hos- 
pital with intense general erythema and severe symptoms of 
poisoning from its too extensive external use. In a case of 
Vidal's general exfoliative dermatitis of two months' duration, 
with intense fever, was brought on in the same way. 

Croton oil and tartar emetic were formerly used as counter- 
irritants, and produced a pustular eruption, often so severe as 
to lead to considerable scarring. 

Cantharides, mustard, and turpentine. — The effects produced 
by these drugs are so well know r n as not to need special descrip- 
tion, and mezereon and savin are rarely used. 

Iodoform. — This drug is a not unfrequent and unsuspected 
cause of eczemaform eruptions chiefly, both in patients and sur- 
geons. Wathen of Clifton \ gives a personal experience of its 
effects excited by handling iodoform gauze; the eruption was of 
a vesiculo-bullous character. Jessop of Leeds also thinks that 
dry iodoform is worse than wet. Wathen found that boric acid 
and lanolin cream, or thick gruel with firm bandaging of each 
finger, gave most relief. 

Orthoform § has been reported by Dubreuilh as having pro- 
duced not only similar eruptions to iodoform, but even gan- 
grene resembling lupus vulgaris treated by pyrogallic acid. 

Mercury only excites irritation in very delicate skins, or when 

* Such a case is recorded as erysipelas in Med. Times and Gazette, 
April 3, 1886. 

f Amer. Jour. Cut. Med., vol. iv. (1886), p. 24. 

% Trans. Derm. Soc. Great Brit, and Ireland, vol. iv. (1898), p. 21. 

§ La Presse Medicate, No. 40 (1901), p. 233. Abs. Brit. Jour. Derm., 
vol. xiii. (1901), p. 277, with several cases. 



DERMATITIS. 463 

used too long or too vigorously in one place; its injurious 
effects may be avoided by frequent ablutions with soap and 
water, and changing the site of its application frequently. 

From its over-use, however, a violent dermatitis may be ex- 
cited. My late colleague, Berkeley Hill, asked me to see a case 
m his wards, of a patient who had rubbed in the ung. hydrarg. 
in a wholesale manner, and had set up a severe pityriasis rubra 
universalis. In former days this was less rare. Moriarty * 
published in his brochure several cases, two fatal in Dr. 
Gregory's practice; but in those days mercury was generally 
overdone. 

Phenyl-Hydrasin-Hydrochlorid. — Although only rarely used in 
medicine as a urine test, the following case is mentioned be- 
cause it illustrates in an extreme degree the growing sensitive- 
ness to the action of an irritant which has once excited derma- 
titis. An analytical chemist displayed an idiosyncrasy towards 
this substance. The eruption had the appearance of an eczema 
and was at first local, but as his sensitiveness increased, not 
only did the primarily local inflammation generalize in a few 
hours, but the minute quantity of vapor conveyed in the clothes 
of his assistant, who visited him at his own house, excited an 
outbreak, f 

2. Anilin dyes, especially the red ones, and J. C. White says 
the black also, are frequent causes of eruption nowadays, 
chiefly through clothing, such as gloves, socks, flannel shirts, 
drawers, etc., dyed with these substances. They are apt to 
excite an itching, red, papular eruption, in extreme cases going 
on to vesicles, pustules, etc. Though limited at first to the 
parts in contact with the dye, the eruption often spreads to a 
considerable distance beyond the part first affected, and while 
the primary attack may only last a week or two, by recur- 
rences the process may go on for months. H. Lee records 
several such instances, and most dermatologists can recall 
cases from their own experience. Accidental contamination 
of the dye with arsenic is supposed to be the real cause of these 
eruptions, but some ascribe them to the anilin itself. 

*" A Description of the Mercurial Lepra," Dublin, 1804. Also Alley, 
" Peculiar Diseases arising from the Exhibition of Mercury," Dublin, 1804. 

f Dr. A. H. Hall, Brit. Jour. Derm., vol. xi. (1899), p. 112, a good account 
with noteworthy remarks. 



464 DISEASES OF THE SKIN. 

Hydro chlorate of paraphcnylcnc diamin * under the influence of 
oxygen is converted into quinone (C 8 H 6 OJ. This property 
has led to its being used as a hair-dye, as tints from auburn to 
jet black may be produced. An aqueous or alcoholic solution 
of the diamin is first brushed or sponged on, and a few seconds 
later oxygenated water is similarly applied with immediate 
effect. 

Unfortunately, quinone sublimes at comparatively low tem- 
peratures, and gives off most irritating vapors, which excites a 
dermatitis of erythema with swelling, papular and vesicular 
lesions being the most common. There is intense itching of 
the skin and pricking of the eyes. The distribution in the 
upper third of the face, the swollen eyelids, the vesiculation of 
the rim of the ears, are suggestive of the cause. 

3. Bichromate of potash. — Workmen who use this drug in their 
trade, such as French polishers, autotype photographers, or 
those concerned in its manufacture, are liable to various erup- 
tions. 

In a case of my own, a French polisher, aet. forty-four, who 
had had several attacks, the eruption was limited to the palms, 
the whole surface of which was thickly covered with pustules 
an eighth to a quarter of an inch in diameter, with a red areola. 
Other workmen suffered similarly, but not so severely. 

B. W. Richardson has given a good account of bichromate of 
potash poisoning. During its manufacture, the air being im- 
pregnated with the salt, the slightest abrasion gives it entrance, 
and an intense destructive inflammation is set up, with suppura- 
tion and ulceration, sometimes down to the bone. The glans 
penis and the septum nasi are liable to be destroyed; and in 
horses, not only the hair, but even the hoofs fall off. Richard- 
son met with six cases among autotypers. In one, the rash 
was " like pityriasis rubra," in another there was " acute 
eczema of the arms and a scaly eruption on the palm like 
psoriasis, and the other cases were either like psoriasis, eczema, 
or pityriasis." 

Hermann \ also describes the ravages (produced both inside 

*Cathelineau, Annates de Derm. u. Syph., vol. vi. (1895)^.24, and 
vol. ix. (1898), p. 63, publishes cases and Mewborn is quoted in Lancet, 
June 29, 1901, p. 1842. 

\Brit. Med. Jour. Epitome, June 22, 1901, from Miinch. ?ned. 
Wochensch., April, 1901. 



DERMATITIS. 465 

and out) in the manufacture of this much-used but dangerous 
salt. 

Aurantia, or Hcxa-nitro-phenyl-amin. — This is an orange-yel- 
low dye much used for cheap yellow leather shoes and other 
goods, and the workers in it are liable to a severe dermatitis on 
their hands. 

In one of my cases the palms were covered with crowded but 
separate hemp-seed vesicles, and the backs also to a less degree 
with vesicles the size of a millet seed, and with marked swell- 
ing; the diagnosis was easy from the orange staining of the 
skin. The liquid is sponged on to the leather to be dyed, hence 
the predominance on the palms. Hellier * of Leeds records 
similar cases. 

Arsenic. — Workmen who prepare skins and furs use lime and 
sulphid of arsenic, and are liable, besides eruptions such as 
may follow any irritant, to a persistent ulcer of the fingers, 
known among French workmen as Pigeonneau.f 

Cocus wood. — Flute-makers who use cocus wood are liable 
to eczemaform dermatitis, probably from a resin in the wood 
which belongs to the family euphorbiacese, an order noted for 
its members exuding irritating and blistering products. 

In one of my cases the eruption began two hours after be- 
ginning to saw up some cocus wood into blocks. His fellow- 
workmen were affected in a minor degree. 

4. Irritant plants not used medicinally. Only a few of these 
can be mentioned, as their name is legion. 

In America, \ especially in the Far West, the Rhus venenata 
and Toxicodendron, popularly called the poison ivy or oak, or 
poisonous sumach or dogwood, are a perfect scourge to trav- 
elers, the irritant, according to Maisch of Philadelphia, being a 
very volatile acid called toxicodendric acid. The variation in 
susceptibility to it is very great, some being able to handle it 
with impunity, while others cannot be in the neighborhood of 
the plant without suffering severely. 

Dr. E. H. Smith of Santa Clara, California, which is the 
home of the plant, wrote to me the following: 

* Brit. Med. Jour., November 19, 1892. 

f Brocq and Landry, A nnales de Derm., vol. ii. (igoi),p. 305, illustrated. 
% A case occurring in England is recorded by Nicholson of Hull in the 
Brit. Med. Jour., March 4, 1899, p. 530, with illustrations of the plant. 
30 



1 



466 DISEASES OF THE SKIN. 

" If the skin is wet from perspiration or rain it will be more 
susceptible, and then persons who have had immunity for years 
will be attacked. 

" It generally begins on the wrists, spreads to the hands, 
especially between the fingers and around the joints. It often 
attacks the genitals or face primarily — to which probably it is 
conveyed by the hands — and spreads thence over the whole 
body in from eight to fourteen days. In face attacks violent 
conjunctivitis may occur. It begins by intense itching and a 
sense of heat, next the skin reddens, and in from two to forty- 
eight hours an herpetiform eruption appears and great edema 
ensues, and it requires about two weeks to run its course. The 
eruption may also be bullous or pustular or combined with the 
other elementary lesions." 

On the subsidence of the eruption several small, whitish, 
smooth-topped deposits may be left beneath the outer layer of 
the skin. These, without fresh exposure to the shrub, spread 
and go through all the characteristic stages exactly as in at- 
tacks from direct contact with the plant. Dr. Smith himself 
went through four such secondary attacks in two months with- 
out having been near the plant, and the last attack was exactly 
like the first. It may be conveyed also indirectly, as by wood 
cut in the vicinity of the rhus and handled by people who have 
not been near the plant. It has also been conveyed by a bath 
brush. 

Eczema and furunculosis are mentioned as secondary effects. 
Dr. Smith scouts the toxicodendric acid theory and invokes a 
" germ " as the cause. His treatment is to apply a lotion, on 
absorbent cotton under oiled silk, of sodii hyposulphitis §ij, 
acid carbolic 5j, aq. distillatae ad Oj. 

I should use the lactate of lead lotion, but many American 
writers say that the treatment should consist of mildly astrin- 
gent lotions, such as Goulard water, bland ointments, and dust- 
ing powders; but better than all, according to Duhring, is the 
fluid extract of grindelia robusta (oj to *iv or §vj of water). 
White recommends black wash, to be applied for a quarter of 
an hour every four hours. Brown advocates bromini Tr|v to 
5J of olive oil or simple ointment. Tannin or sulphate of zinc 
lotions, and vapor baths are also suggested. The pustular 
eruptions are best treated with ointments (iodoform or iodol 



DERMATITIS. 467 

gr. 3 to 5 to the ounce of simple ointment), or oleate of zinc 
or lead, spread upon strips of linen, and applied closely and 
continuously, with rest to the affected parts, especially if they 
are the hands or feet. These plans generally effect a speedy 
cure. 

Primula Obconica* — Since this plant has become a common 
one in conservatories many cases of dermatitis from handling 
it have been published in the journals, and not a few have come 
under my notice. Owing to the cause being usually unsus- 
pected by the patient, difficulties in diagnosis not unfrequently 
arise. A severely itching, papular, erythematous, and vesicular 
eruption of an eczematous type, or occasionally a bullous erup- 
tion, is excited in certain people only, and a red urticaria in a 
few others. The poison is supposed to reside in the hairs of 
the plant. 

The victims are generally amateur or professional gardeners, 
and the apparently mysterious recurrence of the eruption each 
time they handle the plant leads to all sorts of errors in the 
diagnosis of the cause. The irregular distribution of the 
lesions and the predominance in exposed parts or in regions 
frequently touched by the hands will often give a clew to the 
cause being from without. 

The treatment would be the same as for rhus poisoning, for 
most of the rashes from these causes. Probably lactate of lead 
lotion would be the most universally applicable, and calamin 
lotion where the skin is unbroken. 

Feigned Eruptions, f Besides their legitimate use, various 
irritants may be fraudulently employed, chiefly by hysterical 
women, mendicants, soldiers, prisoners, or domestic servants, 
either with a sordid or morbid object of obtaining sympathy, or 
to avoid some irksome duties. Unless the physician has a 
sound knowledge of the effects of true disease, they may give a 
good deal of trouble, and the impostors are often successful in 
their object when there is an apparent absence of adequate 

* Brit. Med. Jour.. September 28, i88g, and vol. ii., 1890. Lancet, ditto. 

f A good many examples are to be found in vol. i. (1870) of the Brit. 
Med. Jour., by the late Mr. Startin, Hilton Fagge, W. Roberts, etc. 
See also a clinical lecture by Colcott Fox, Illustrated Med. News, 
November 2, 1880. 



468 DISEASES OF THE SKIN. 

motive. The following points will often aid in detection; but 
let not the young physician expect credit for so doing, as the 
friends of the hysterical one are often almost as angry with the 
discoverer as they are with the perpetrator of the deceit. A 
circumstance which often confuses the issue is that a genuine 
lesion, the result of accident or disease, often precedes and sug- 
gests the fraudulent imitation. 

The eruption or lesion nearly always differs from what may 
be called the natural eruption it is supposed to represent, and 
is often unlike any known disease. Thus, if it is an erythema, 
it is probably sharply defined and irregular in shape, and with 
a clumsy operator may even be angular in outline. If it is 
gangrenous and produced by a liquid caustic, in addition to the 
irregularity it is common to find that some drops have been 
spilled away from the main lesion, or that it has run down in a 
streak, or that it has damaged the clothing or stained the fin- 
gers or nails. Then the lesions are either single or few in num- 
ber at least, at each supposed outbreak, though, when the de- 
ception has lasted a long time, the number of lesions in the 
aggregate may be very large. They are usually arranged un- 
symmetrically, mainly on the left side, especially on -the limbs, 
or at all events in easily accessible positions. The fraud may 
be betrayed by traces of the special agent employed on the skin 
or clothing, such as particles of mustard or cantharides, the 
smell of turpentine, the yellow stain of nitric acid, etc. Spon- 
taneous superficial gangrene, especially in a young woman, 
should always be regarded with suspicion. 

A few examples may be given. A girl of seven was brought 
to U. C. H. for longitudinal scabbed patches on the back of the 
phalanges, for which she had been sent to the seaside on 
several occasions; she confessed that she liked going very 
much, and stopping her jaunts stopped the lesions, which were 
probably burns with a match. A girl of eighteen simulated 
chromidrosis. While she was having a bath, blacklead was 
found in her pockets. In the case of a servant with a gan- 
grenous patch on the leg, a yellow streak ran round to the calf 
away from the main patch. The diseases most frequently 
simulated are erythema, eczema, pemphigus, gangrene, ulcer- 
ations, morbid growths or discolorations, changes in the cuta- 
neous secretions, etc. 



DERMATITIS MEDICAMENTOSA. 469 

C. Fox and Sangster * have each reported a case produced 
by mechanical means; the patient rubbed a spot with the end of 
her fingers, moistened with saliva, until a sore was the result. 
Cases such as these have been reported by Erasmus Wilson and 
others as " neurotic excoriations," and correctly so, but not in 
the sense intended by the authors. Sangster f showed such a 
case at the Congress in 1881, which at the time he thought 
genuine, but subsequently ascertained to be produced in the 
same way as his other case already mentioned. Bristowe \ 
also records a case where pieces of skin were snipped out with 
scissors. 

The best chance of stopping these tricks is not to let the pa- 
tient know that she is suspected, but to put her under secret 
surveillance until she can be detected in flagrante delicto, so that 
she is convinced the kk game is up." Otherwise the accusation 
will only lead to indignant denials, the modus operandi will re- 
main undetected, and she will either persist in her imposture 
under different auspices, or will take the opportunity of a 
graceful retreat by getting well under some other doctor's treat- 
ment. Thus the diagnosis of factitious origin will appear to 
have been incorrect. 



DERMATITIS MEDICAMENTOSA. § 

Synonym. — Drug eruptions. 

It is fortunately uncommon for eruptions to be produced by 
drugs, yet the number that may produce them is considerable. 
In the majority of instances there is either an idiosyncrasy on 

* Lancet, December 30, 1882. 

f Lancet, June 3, 1882. 

% Lancet, January, 1883. 

% Literature. — G. Behrend. " Zur allgem. Diagnostik der Arzneiaus- 
schlage," Berlin klin. Wochensch,, vol. xvi. (1879), p. 714. Berenguier, 
"Des eruptions provoquees par l'ingestion des medicaments," "These de 
Paris," 1874, p. 45. Morrow on " Drug Exanthemata," etc., New York 
Med. Jour., vol. xxxi. (1880), p. 244; and a monograph published by 
Wood & Co., New York, 1887, with bibliography, of which a new edition 
for the Syd. Soc. has been prepared by Colcott Fox in "Selected Mono- 
graphs on Dermatology," 1893, with copious bibliography. Van Harlin- 
gen, "Medicinal Eruptions," A mer. Arch, of Derm., vol. vi., p. ^37— 
very complete and full of references. Discussion on Drug Eruptions, 



47° 



DISEASES OF THE SKIN. 



the part of the patient, or renal or cardiac disease interferes with 
elimination, or the dose is large, the medicine long continued, 
or a combination of these factors is present. Thus, there are 
many instances where a very small dose has been, and always is, 
capable of producing an eruption in that particular patient, and 
in many the susceptibility tends to increase, and in these a larger 
dose, or perseverance in taking the drug after the appearance 
of the eruption, may considerably aggravate the form it takes; 
a partial erythema becoming general, and even hemorrhagic 
or gangrenous, or a vesicular eruption becoming bullous or 
pustular. Whilst there are many forms of eruption due to 
drugs, only two — iodine and bromine, and their salts — are 
capable of exciting lesions which are special and peculiar. In 
all the rest the eruption itself follows a recognized type, and it 
is only from the circumstances under which it occurs that the 
cause is ascertainable. 

In the following account only those eruptive phenomena are 
considered which are the result of absorption of the drug into 
the organism either from ingestion by the mouth or rectum, 
subcutaneous injection, or absorption through a wound or 
even the unbroken skin, as in mercurial inunction. 

Inflammations produced by drug irritants, such as arnica, 
tartar emetic, etc., are described with lesions produced by other 
irritants under Dermatitis. 

Antifebrin or Acetanilid produces a kind of cyanosis when 
the drug is long continued or the dose is large. The slaty- 
colored anaemia is very suggestive, and is probably due to a 
change different to that of venous blood, in a case of poisoning, 
the blood being dark blue, as in anilin poisoning. Small doses 
will sometimes produce it. Exalgin and monobrom-acetanilid 
have a similar effect, the latter sometimes after a small dose. 
It has been suggested that free anilin is produced. 

Antipyrin.* Since this drug has come into common use 
numerous cases of eruption have been reported. The back of 

Trans, of Internat. Med. Cong. Berlin, i8qo. Also Brooke and C. Fox's 
papers in Brit. Jour. Derm., October and November, 1890. "Derma- 
toses produced by Drugs," by Jadassohn. A translation by Elkind forms 
one of the Selected Essays of vol. clxx. (1900) of the Syd. Soc. 

* Literature. — This is very extensive. Morrow's Syd. Soc. Edit, gives 



DERMATITIS MEDICAMENTOSA. 47 i 

the hands is especially liable to be attacked, and in one of my 
cases was the only part. The eruption may be erythematous, 
purpuric, urticarial, vesicular, or bullous. The erythematous 
is by far the most common, and is often followed by pigmenta- 
tion. 

Spitz collected fifty-two cases, and of these forty-one were 
morbilliform, four urticarial, and the others papular erythema. 
It may also be scarlatiniform, in finger-nail patches up to 
patches the size of a crown-piece, or there may be extensive 
diffuse redness, or there may also be pearly spots. 

The eruption may be general or partial, but symmetrical, 
affects the chest, abdomen, and back, the limbs and the ex- 
tensor aspects more than the flexor, but every part, even the 
palms and soles (Ernst), has been involved in one case or other. 
Benzler and Ballin * have had similar cases. In a case of 
Archer's bullae formed a ring round the arms, the eruption 
being preceded by intense itching. The mouth and genitals 
may also be affected. The morbilliform rash may be associ- 
ated with oro-nasal catarrh. The patches may be formed by 
coalescence of one of the papular forms, as in Blomfield's cases, 
or the smaller patches may arise primarily and closely simulate 
the macular syphilid, especially when the oral mucous mem- 
brane is involved and mucous plaques are simulated, or when 
the eruption is on the palmar surface as well as the back of the 
hands. 

In one of Blomfield's cases it began inside the knee, and 
spread from that all over the trunk; the eruption was of a deep 
red, papular or morbilliform, becoming confluent, but with 
free intervals of white healthy skin which gave it a marbled ap- 
pearance, or it enlarged into patches half an inch in diameter; 
these began to clear in the center, and faded altogether in from 
five days to a week. There was itching in most cases, moderate 
desquamation, and some staining left. Acuminate miliaria-like 
papules, with profuse perspiration, have been noted. It sel- 
dom lasts more than five days, and may be followed by des- 
quamation and pigmentation. It generally recurs if the drug is 
resumed even in small doses. At the same time, in several in- 

references to 1892, and Apolant, Archiv f. Derm. u. Syfth., vol. xlvi. 
(i8q8), p. 345, gives a very copious bibliography. 
* Jadassohn, loc. cit., note, p. 229. 



472 DISEASES OF THE SKIN. 

stances, the rash faded without the drug being stopped. A. 
Fournier records three cases in which the penis turned black 
after antipyrin from pigmentation following an erythematous 
eruption. The erythematous, urticarial, and slighter vesicular 
eruptions may occur after moderate doses, but the purpuric 
and bullous eruptions have generally been after large doses. 
By rubbing in a ten per cent, ointment Wechselmann produced 
in susceptible patients the same eruption as was produced by 
the internal administration of the drug. Strauss records a case 
of purpura limited to the back and lower limbs, but very large 
doses, producing collapse, had been administered; while in 
most of the other cases, moderate doses, such as twelve grains, 
had been given. Veiel * records a case of bullous eruption in 
a man of thirty-three which appeared on the glans penis, be- 
tween the toes, on the lips and hard palate, while it was red and 
wheal-like on the palms and soles. Petrini's f case was still 
more developed, some of the bullae being the size of a five-franc 
piece, and the eruption was nearly universally distributed. 

The physiological action of the drug is of itself a predispos- 
ing factor. It produces paralysis of the vaso-motors followed 
by dilatation of the cutaneous vessels. After large doses it 
occurs free in the urine. Mibelli has demonstrated antipyrin 
in the liquid of bullae by perchlorid of iron, which turns it red, 
and Tonnel and Raviart by iodin dissolved with iodid of 
potassium. 

Argyria. See under Pigmentation. 

Arsenic.^ This, being a powerful irritant, is liable to produce 
inflammatory eruptions when in direct contact with the skin, but 

* Archiv f. Derm. u. Syph., vol. xxiii. (1891), p. 33. 

\ A?m. de Derm, et de Syph., vol. iii. (1892), p. 170. 

% Literature. — Imbert-Gourbeyre, " Histoire des eruptions arsenicales," 
Moniteur des Hop., 1867, p. 317, quoted by Van Harlingen ; also " De 
Taction de l'arsenic sur la peau," Paris, 1871. 

J. Meneau of Bourboule, Annates de Der?n. et de Syph., vol. vii. (1897), 
p. 305. With copious bibliography and good abs., Brit. Jour. Derm., 
vol. ix. (1897), p. 368. 

" The Action of Arsenic on the Skin, as observed in the Arsenical Beer 
Epidemic," H. G. Brooke and Leslie Roberts, Brit. Jour Derm., vol. xiii. 
(1901), p. 122, highly illustrated. 

" An Account of the Epidemic Outbreak of Arsenical Poisoning in 



DERMATITIS MEDICAMENTOSA. 473 

as it is only like other irritants in this respect, these eruptions 
need not be gone into here. Eruptions of various kinds may, 
however, arise from its internal administration. Imbert-Gour- 
beyre, Meneau, Brooke, and Roberts have written very good 
monographs on this subject. Urticaria is one of the most com- 
mon forms of eruption; according to Imbert-Gourbeyre, four 
minims three times a day for three days produced it in one case ; 
Meneau, however, does not confirm this. 

Imbert-Gourbeyre states that the following eruptions may 
occur: erysipelas-like dermatitis of the face and eyelids, often 
becoming vesicular; a papular rash on the face, neck, and hands 
morbilliform or like a papular syphilid. The papules are few, 
small, and separate at first, but subsequently in groups; these 
enlarge and coalesce into patches, which may be large and dis- 
seminated on the neck, or there may be pin's-head-sized papules 
on the forearms, with itching. There may also be erythemato- 
bullous, pustular, ulcerative, or gangrenous eruptions, but they 
have, as a rule, only followed large and toxic doses, but Bazin, 
after giving one-thirtieth of a grain once a day for two weeks in 
a case of eczema, observed an eruption limited to the right flank, 
consisting of discrete papules and pustules, an ulcer one centi- 
meter broad, and two ecthymatous lesions, but this may have 
been a severe zoster only. Gangrenous lesions especially affect 
the genitals, but are not confined to them. 

Meneau adds to this list pruritus and general or local des- 
quamation, scarlatiniform erythema, petechias (rare); vesicular 
eruptions * simulating scabies, eczema, or miliary vesicles. 

Herpes zoster has followed the administration of arsenic in 
so many instances, as first pointed out by Hutchinson, who has 
been corroborated by so many authors, that it can be no acci- 
dental concomitant. Thus Railton in ten cases of therapeutic 
dosing for chorea noted three cases of herpes zoster, and sev- 
eral have fallen under my own notice. Sturk produced two at- 
tacks of facial zoster by giving arsenic. Meneau says the 

1900," E. S. Reynolds, Med. Chir. Soc. Trans , vol lxxxiv., 1900. The 
nerve symptoms have a prominent place, but there are some valuable 
observations on the skin lesions. 

* Ohmann-Dumesnil records a case of vesicular eruption on the face 
and buttocks from a single large dose of arsenic. Abs. Brit. Jour. 
Derm., vol. xiii. (1901), p. 192. 



474 DISEASES OF THE SKIN. 

vesicles are smaller than those of ordinary zoster, and may be 
accompanied by erythema, eczema, edema, desquamations, etc. 
I am inclined to think the distinction fanciful, and believe that 
arsenical zoster is not different to ordinary zoster; and as 
arsenic is known to be capable of producing peripheral neuritis 
and probably inflammation of the ganglion also, the explana- 
tion is not far to seek. The very large number of cases in the 
Manchester epidemic is conclusive of the relationship and gave 
Reynolds the first clew. Probably the most common results of 
prolonged or excessive administration of arsenic are general 
pigmentation and keratosis, preceded and accompanied by 
hyperidrosis of the palms and soles. 

Pigmentation following arsenic is now well known.* 
Reynolds says that it is always preceded by erythema and fol- 
lowed by pigmentation, but I do not think this is always so. At 
the commencement, as can be well seen on the abdomen, the 
hair follicles themselves escape, so that there are white dots on 
a dark ground, which is very characteristic, but ultimately the 
discoloration is uniform. The color is sepia or yellowish-brown, 
occasionally almost black. There are usually lighter areas 
interspersed in the diffuse form. It may also occur in dots or 
in patches of variable size. In children it may occur even with 
moderate doses, but in adults it is only after large doses or 
long-continued use. The neck, axillae, abdomen, and groins are 
the parts first involved, and the exposed parts are less pigmented 
than covered parts. Gubler thinks it is true pigmentation, and 
not due to mere deposition of the metal in the tissues. Against 
this may be cited the fact that when psoriasis is cured by arsenic, 
marked pigmentation often ensues, strictly limited to the sites 
of previous eruptions. Recent pigmentation tends to fade, but 
when due to very prolonged administration much of it may be 
permanent; I have seen pigmentation of several years' dura- 
tion. Brooke and Roberts show that arsenic is deposited in the 
epidermis. 

Keratosis, or thickening of the horny layers of the palms and 
soles, begins round the sweat follicles, so that the surface is cov- 
ered with small nodular shagreen-like or warty thickenings. 

* Author's Atlas, Plate XXXVII. , illustrates stages of pigmentation and 
early keratosis, and Plate XLIV., Figs. 3 and 4, a more advanced condi- 
tion of the latter. 



DERMATITIS MEDICAMENTOSA. 475 

Gradually the intervals are filled up, and uniform thickening of 
the horny layer or keratosis is established just like the con- 
genital form. An analogous thickening occurs over the 
knuckles and elbows, a whitish powdery appearance being pro- 
duced, with slight resemblance to psoriasis. 

In the more severe cases, such as in the Manchester epidemic, 
the palms and soles were red, tender, and there was numbness, 
tingling formication, and anesthesia (Erythromelalgia). Gen- 
eral itching was often present and other symptoms of peri- 
pheral neuritis. 

Hutchinson * has drawn attention to the occurrence of epi- 
thelioma of the palm due to arsenic. I have had an opportunity 
of observing how this occurs. The warty thickening already 
described on the palms becomes more pronounced in some of the 
lesions, and epithelioma gradually develops on the papillary 
overgrowth. This in one of my cases occurred forty years after 
the arsenic had been given up, and also illustrates how persistent 
the keratosis may be; but slight degrees of it may disappear. 
Arsenic is very liable to aggravate acute forms of skin inflam- 
mation. 

The nutrition of the nails is altered; they are whiter, cracked, 
thin, and towards the tip almost papery and much flattened 
(Reynolds). In some cases there were transverse ridges. 

Belladonna. A diffuse erythematous blush and a scarlatini- 
form erythema, chiefly affecting the face and neck, have been de- 
scribed as due to belladonna, occurring chiefly in children, even 
when small doses have been taken. I have seen large red 
patches paling on pressure, and the whole face and trunk suf- 
fused deep red in cases of belladonna-poisoning, but have rarely 
met with it after medicinal doses, although I have prescribed it 
in twenty- or thirty-minim doses of the tincture, in hundreds of 
cases of whooping cough. In a case at St. George's Hospital, 
kindly shown me by Dr. Whipham, a man of forty with sup- 
posed typhilitis wore a belladonna plaster for a week, and then 
took two seven-drop doses of the tincture; the next day the 
hands and feet were swollen, red, and tense. When I saw him 
the palms were deep red with thickening of the epidermis, the 

* Hutchinson's smaller Atlas, Plate XX. Plates XVIII. and XIX. show 
keratosis of the elbows and hands. 



476 DISEASES OF THE SKIN. 

soles were less affected; over the knuckles and all points of 
pressure and redness was intense, and capillary pulsation could 
be demonstrated by slightly flexing the joint. Dreyfous records 
a scarlatiniform eruption and papular erythema, with intense 
itching, after taking two grains of the extract in the course of 
five days, followed by a vapor bath. 

External applications of belladonna preparations frequently 
excite erythematous, papular, and vesicular eruptions. In one 
of my cases, on two occasions, belladonna fomentations made 
with the glycerin of belladonna extract, and applied to a gouty 
foot, produced a copious and severe outbreak of vesicles and 
bullae on the foot. The emplastrum belladonna often excites an 
itching erythematous or even eczemaform eruption; and Tom 
Robinson * records a case in which splashes of fresh belladonna 
juice or atropin powder set up a smart eczemaform eruption in 
a pharmacist's employee. 

Benzoate of Soda. Nicolle and Halipre f record a case of 
erythematous patches and papules of small size and elevation; 
after three doses of fifty centigrams they came chiefly on the 
extensor aspect of the wrists, elbows, and knees, did not spread 
after the drug was stopped, and began to fade in twenty-four 
hours. 

Boric Acid. Molodenkow \ of Moscow washed out a pleural 
and a lumbar abscess cavity with a five per cent, solution for an 
hour, a large quantity of the drug being employed, and " the 
next evening erythema appeared on the face, and spread on the 
third day to the neck, chest, and abdomen, then to the thighs, 
small vesicles appeared on the face and throat, the sight became 
dim, and both patients died, conscious to the last, one on the 
fourth, the other on the third day." Bruzelius § reports a simi- 
lar case, but with recovery, after rectal injections of two pints of 
a four per cent, solution. Another case is reported by Johnson 
of Norway. Vincent reports two cases, both in subjects with 

*Case of cutaneous antipathy to atropin. Brit. Med. Jour., Sep- 
tember 26, 1896, p. 881. 

f Quoted in abs. in Mai. Cut., vol. x. (1898), p. 709, from Normandie 
Medicate, 1898. 

% Molodenkow, quoted in Lancet, May 6, 1882. 

§ Bruzelius, Hygeia, 1882. 



DERMATITIS MEDICAMENTOSA. 



477 



renal disease, Corlett saw six cases when treating diphtheria with 
5j doses of the drug, and G. Lemoine met with a case with 
febrile symptoms from dressing a bed-sore with the powdered 
boric acid. 

Burning of the skin, which swelled, looked charred, and sub- 
sequently exfoliated, followed the packing of the upper third of 
the vagina with boric acid in a case of Welch's. Fordyce * gave 
thirty grains daily for a month for cystitis : a multiform 
erythema developed on the trunk and spread over the extremi- 
ties; there was extreme and painful edema of the eyelids and 
conjunctivitis. The drug can be detected in the urine, \ and as 
it is commonly used in milk and other foods as a preservative, 
this may be useful for diagnosis. 

Borax, given internally, in five-grain doses, for epilepsy ap- 
peared to produce psoriasis of the usual type in three cases 
under Gowers. This experience is confirmed by Liveing. Fere 
and Lamy record two cases of eczema with gastric disturbance 
excited by it, but both patients had seborrhea of the scalp, and 
had had previous attacks of eczema. There is also a peculiar 
dryness of the skin and mucous membranes, the latter being red- 
dened and denuded of epithelium, and sometimes the hair falls 
out. 

Fere J also records pink or red confluent plaques followed by 
fine desquamation. Papular eruptions with or without pruritus, 
which may become confluent and be followed by desquamation. 
Petechias are sometimes seen. 

A diffuse, erythematous, morbilliform eruption followed the 
administration of " tartarus boraxatus " § in large doses for two 
weeks by Alexander. 

Bromine and Bromids. || The eruptions met with in connec- 

* Amer. Jour. Cut. Dz's., vol. xiii. (1895), p. 499. 

f Make the urine alkaline by soda, evaporate to a syrup, mix with some 
pure white sand, evaporate to dryness. Powder the residue, cover it 
with alcohol, and add a few drops of strong sulphuric acid. On igniting 
the alcohol it will burn with a green or green-bordered flame. — Morrow, 
Syd. Soc. Ed., p. 403. 

%Brit. Med. Jour. Epitome, January 6, 1895, "Borism." 

§ Tartarus boraxatus is supposed to be borated cream of tartar. The 
case was published in Viertelj.f. Derm. u. Syph., vol. xi., p. no. 

|| Author's Atlas, Plate XXXV., shows an extreme case from long- 
continued ingestion of the drug of the confluent form. It also illustrates 



478 DISEASES OF THE SKIN. 

tion with these drugs are pustular, erythematous, urticarial, 
bullous, and squamous. The description of bromid of potassium 
eruptions applies to those produced by any of the other salts of 
bromin. 

The great majority are pustular, and these may be discrete, 
acneiform, furuncular and confluent, or anthracoid. The dis- 
crete acneiform is very common upon the face, chest, or back, 
the scalp, and round the hair follicles of the thigh and leg. The 
pustules are yellow, on a raised red base, from a hemp seed to 
a pea in size. The confluent form is less common. Some of the 
earliest cases were reported by Cholmeley, Lees,* and myself, f 
and they are now too numerous to specify. It is very distinct 
from all other eruptions except those of iodid, which are often 
very similar, but usually distinguishable. Convex, crimson, 
much-raised, circumscribed, oval, or roundish elevations are 
formed on the face and limbs, rarely on the trunk. The top of 
these elevations is covered with minute, closely aggregated, yel- 
low, pustular points, almost like a carbuncle, but there is no red 
border or brawny induration, and the swellings are soft, almost 
fluctuating, and dry into a scab in the center, even while there 
are pustular points near the periphery. Ultimately a yellow- 
ish or black (from hemorrhage), irregularly sulcated scab is 
formed, and when this is removed an irregular ulcer may be left, 
but, as a rule, if the drug is not continued the lesions dry, the 
swelling subsides, and the scab is thrown off, without even 
leaving a scar, though the skin has a purplish or brownish stain 
on the site of the eruption for a considerable time. There are 
nearly always some discrete lesions as well. One peculiarity is 
its tendency to commence in scar tissue; in three instances, in 
my own experience, it was on the site of the vaccination scars, 
and in one limited to that position, the lesion, with its central 
scab, being very like a vaccination pustule of about the tenth 
day; in the case of an adult epileptic, the eruption was limited to 
the scar of an old strumous ulcer of the leg, in another it was on 
the scar of a recent burn. Another point is that the eruption 

lesions, which have been called by various observers granulomatous, 
papillomatous, ulcerative, and even " epithelial ulcer." 

* Path. Soc. Trans., vol. xxxviii. (1877), p. 247, with colored plate. 

f Ibid., vol. xxix. (1878), p. 252, with colored plate. Both of these give 
a very good representation of the eruption. 



DERMA TITIS MEDICAMENTOSA. 



479 



continues to come out, and sometimes does not even commence, 
until after the drug has been stopped for some days, or even 
weeks; and Cavafy showed a case at the London Dermatological 
Society in which there was an eruption very like the " Iodid 
Hydroa " of the Sydenham Society's Atlas, and the patient had 
not taken bromids for three months previously. 

Infants are more liable to confluent eruptions than adults, and 
it has been thought that a combination of iodid with bromid in- 
creases the liability to them. Deficient kidney elimination is 
also a factor both for this and iodid eruptions, but very small 
doses will produce the lesion where there is an idiosyncrasy, as 
little as a grain three times a day in an infant given by the 
mouth, and it has occurred in sucklings whose mothers were 
taking the drug. As a rule, however, large doses are more 
likely to produce it; hence it is common in France, where doses 
of ten grams and upwards are not infrequently given. Papil- 
lary hypertrophy sometimes follows, as well as accompanies, 
the eruption, as I have myself seen; while Veiel describes large 
prominences on the face and legs, like ordinary warts, and not 
consecutive to other lesions. Fatal cases are known, but due 
to the general effects of the drug, not to the skin lesions. Two 
are reported by Hameau and Eigner, and were women, aet. 
twenty-two and nineteen respectively. Both had been taking 
enormous doses for a year previously. In two epileptics re- 
ported by Greenlees only twenty-five grains three times a day 
had been given for a few weeks. 

A furunculoid eruption, and groups of indolent acneiform 
pustules on the legs, which left scars, have been described by 
Yoisin. Both he and Van Harlingen describe ecthymaform 
pustules, but these may well be accidental from pus inoculation. 

Erythematous eruptions may be diffuse but limited to the 
lower extremities (Veiel), in patches, finger-nail to pea-sized, in 
various parts of the body, roseolous (Bedford-Brown) and papu- 
lar, but this is usually an early stage of the pustular form. Fur- 
ther erythema nodosum, or something very like it, is described 
by both Voisin and Veiel, occurring on the legs. In a case of 
Horrocks * similar lesions came on the legs and extensor sur- 
face of the arms and forearms, and subsequently indistinct 
vesicles formed upon them. 

* Path. Trans., vol. xxxiv., p. 272, and also p. 273. 



480 DISEASES OF THE SKIN. 

In this form of eruption, as I have seen it, the lesions are 
more brawny and defined, and less tender than in true erythema 
nodosum, and not necessarily situated over the superficial bones. 

Echeverria describes a case with a diffuse, papular eruption 
over the elbows, knees, legs, and back of hands. He says that 
a brownish discoloration of the forehead and neck is also to be 
met with, and that painful subcutaneous suppuration may occur. 
Duhring saw a diffuse erythema of the face and neck, accom- 
panied by maculo-papules, flat papules, and pustules. 

All the eruptions are probably only stages or modifications of 
the ordinary pustular eruptions. Urticaria is spoken of as of 
doubtful occurrence; it may occur after iodid, and probably after 
bromid. Saundby's case was complicated by the patient taking 
thirty minims of hydrobromic acid at the same time as the 
bromid. 

Veiel and others describes a squamous eruption like sebor- 
rhea, and Voisin records a moist eczema of the legs with 
pityriasis capitis. A bullous eruption is recorded by Wiggles- 
worth * in an epileptic ladv who had taken bromid for some 
time. Slightly acuminate bullae came out on the trunk, from the 
size of a split pea to that of the finger-tip; some were hemor- 
rhagic; they ruptured and left an excoriated surface; the rash 
disappeared soon after the discontinuance of the bromid. 

A bromoform eruption in a child consisted of papules, pustules, 
superficial and raised ulcers, and papillomatous tumors of the 
characters already described for bromids; twenty-three grains 
spread over twenty-five days had been given for pertussis. f 

Infiltrated granulomatous patches occasionally occur, as in 
Pini's \ case, similar to what are rather more frequently seen 
after iodids. 

Anatomy. — Much dispute has arisen as to whether the sebaceous glands 
are the seat of the lesion. The anatomy of the pustular lesions has been 
investigated by Neumann, § S. Mackenzie,! jointly by C. Fox and Gibbes, 
Jacquet,^" etc. Neumann found that the inflammation began first round 

* Arch.f. Derm., vol. v. (1879), p. 371, in discussion on iodid bullae, 
f Julius Miiller, American Medico-Surgical Bulletin. 
\Archivf. Derm. u. Syph., vol. Hi. (1900), p. 163, illustrated. 
§ Viertelj . f. Derm. u. Syph., 1874, P- 395- 
I Path. Trans., vol. xxxv. (1884), p. 400, with lithographs. 
%Med. Soc. Trans., vol. ix. (1886), p. 51. 



DERMATITIS MEDICAMENTOSA. 481 

the sebaceous follicles, and later the hair follicles and sweat glands were 
involved, while there was considerable hyperplasia of the epithelial layers. 
S. Mackenzie found that there was : (1) active hyperemia of the corium, 
with exudation of colored and colorless corpuscles, especially in the 
neighborhood of the papillae ; (2) minute abscesses in the vicinity of the 
hair follicles and sebaceous glands ; (3) small multilocular vesicles in 
superficial layers of the epidermis. Hence he infers that the fluid part 
of the exudation tends to reach the surface and form bullae more rapidly 
than the corpuscular part, which accumulates near the hair follicles and 
sebaceous glands, and forms points of suppuration. Fox and Gibbes 
found that the changes were chiefly perivascular, but involved the sweat- 
gland ducts, and regarded any changes near the sebaceous glands as 
accidental. Seguin found great hyperplasia of the prickle-cell layer. 
On the whole, it seems probable that the seat of the lesions is at the 
vessels, and that the glands or follicles are involved simply because they 
are highly vascularized, but that they are not always involved, or in any 
way necessary for the production of the lesions, is shown by their occur- 
ence in, and even preference for, scar tissue. 

Diagnosis. — The discrete lesions differ somewhat from ordi- 
nary acne, they suppurate more freely, and the contents are 
more distinctly purulent and of thinner consistency; the red base 
is usually of a dusky hue, and there has been no antecedent 
comedo. These differences are just sufficient to excite inquiry 
as to whether bromid is being taken. The confluent form is 
very distinctive. The aggregation of pustular points on a raised 
red plateau, too soft for a carbuncle, and comparatively pain- 
less, and perhaps the position of the lesions, render the diagnosis 
possible from everything but the similar iodid eruption. More- 
over, confluent pustular lesions are exceptional in iodid erup- 
tions and common in bromid rashes. On the other hand, bul- 
lous eruptions are rare after bromids and comparatively com- 
mon after iodids. 

Treatment. — Stop the administration of the drug, give liq. 
arsenicalis in TTXiij to Trjv doses three times a day, and apply 
subacetate of lead lotion two per cent., or salicylic acid gr. 1 to 
5j of water, on lint covered with oiled silk, as recommended by 
Prowse. Where, as in epilepsy, it is necessary to go on with 
the bromid, the addition of a drop or two of liq. arsenicalis to 
each dose of the mixture will materially control, if it does not 
entirely prevent, the eruption; and in most cases, then, it is safe 
to stop the bromid for two days in each week. The liability to 
pigmentation and keratosis from the long-continued administra- 
31 



482 DISEASES OF THE SKIN. 

tion of arsenic must be borne in mind. I have repeatedly seen 
both in chronic epileptics. 

Fere tried to produce intestinal antisepsis by giving naphthol 
/? and salicylate of bismuth, and the fungating eruption disap- 
peared without the bromid being stopped. Salol gr. 5, ter die, 
would have the same effect, and would not be injurious, as 
arsenic is, when taken for long periods. 

Cannabis Indica. Nevins Hyde * reports a case, the only 
one on record, in which a grain of the extract, taken overnight, 
produced the next morning a general eruption consisting of 
disseminated vesicles, with clear contents, from a pin's point to 
a pea in size, attended with considerable itching, and subsiding 
without treatment in a few days, leaving a transient pigmen- 
tation. 

Cantharides. Erythematous and papular eruptions in vari- 
ous parts of the body, but especially in the genitals, have fol- 
lowed the internal use of cantharides. Generalized vesicular 
and other eruptions starting at, or at a distance from, the site 
of a blister are analogous to what often occurs after irritant der- 
matitis from any cause. 

Capsicum. An erythematous eruption may sometimes fol- 
low the ingestion of large doses, and Allen reports a case of 
papulo-vesicular eruption all over the body after its administra- 
tion internally. 

Chinolinf has been given in typhoid fever. In six out of 
twenty cases Draper observed an erythematous rash. Henchen 
and Laache publish cases. 

Chloral Hydrate. Various eruptions, mostly of erythematous 
type, have resulted from the use of chloral. The most common 
is the kind of which Gee reports two cases : a dusky red papular 
eruption, surrounded by a more diffuse redness of the face and 
neck, and patchy or mottled red spots on the extremities, espe- 
cially near the articulations, which were all more or less affected. 
The eruptions are generally of short duration, and there is no 
itching or constitutional disturbance as a rule, but there are ex- 

* New York Med. Record, May 11, 1878. 

f Morrow, Syd. Soc. Ed. Note by Fox, p. 455. 



DERMATITIS MEDICAMENTOSA. 483 

ceptions, as in Kobner's case, where there was burning and 
itching and desquamation, followed by persistent general 
erythema with infiltration of the skin. Letten's case of poison- 
ing had itching and round or conical yellow papules which lasted 
a week. 

General scarlatiniform eruptions, followed by desquamations, 
are less frequent. The oral and pharyngeal mucous membrane 
is also red, increasing the liability of its being mistaken for 
scarlatina, as a rise of two or three degrees of temperature is not 
uncommon. The Chloral Committee of the Clinical Society * 
had the following skin lesions reported to them: A defective 
circulation of the hands, with blueness, and, in one case, a line 
of ulceration round each nail; a bullous eruption called pom- 
pholyx; an erysipelatous redness of the face; intense redness and 
flushing of the face and scalp; a large patch of papular efflores- 
cence of a purplish-red color; a lichenoid eruption and ulcers; 
and itching of the legs without eruption. In nearly all these 
cases the drug had been taken for some time, often in large 
doses. Stimulants are said to increase the eruption. In a case 
of Kirn's the eruption began as discrete red papules, which be- 
came confluent; and as the drug was not stopped, it went on to 
vesicles, pustules, and scaling of an eczematous type, at first, 
and then diffuse desquamation, shedding of all the nails, axillary 
abscesses, and a continuous rise of temperature reaching to 
106 F. The same author and Crichton Browne record purpura 
and petechias following its prolonged use, in one case leading 
to death; and deep ulcer and vesication over points of pres- 
sure has been observed by Reimer. Involvement of the oral 
mucous membrane, tongue, and conjunctiva has been recorded 
from congestion to blistering and ulceration. 

Urticaria has also been met with by Gaucher, Chapman, etc., 
of course, with itching and burning. According to Barbilion, 
any form of alcohol given with it, especially in children, greatly 
increases the liability to eruptions. It has been said that neu- 
rotic subjects are more sensitive to it, but they are just the 
people who take it most. 

Chloralamid. Pye-Smith \ had a case of a brewer's cellar- 

* Clin. Soc. Trans., vol. xiii. p. 121. 

\Ibid., vol. xxiii. (189c), p. 137, with colored plate. 



484 DISEASES OF THE SKIN. 

man, with aortic disease, who took two forty-grain doses every 
night for twelve nights. On the thirteenth day a diffuse, bright 
red scarlatiniform eruption appeared on the face and soon be- 
came universal, including the mucous membranes. The tem- 
perature reached 103 F., and there were other febrile symp- 
toms, with running at the nose and eyes. The eruption lasted 
a week, and was followed by large flaky desquamation. 

Chlorate of Potassium. Stelwagon * reports a case in which 
a " fiery erythematous and papular eruption," similar to 
erythema multiforme, and without subjective symptoms, io\- 
lowed the use of tablets of chlorate of potassium on four occa- 
sions, when about one hundred grains in all had been taken. 
Brouardel and Lhote noted bluish spots on the skin, sometimes 
a general cyanosis and sometimes an icteric tint, where poison- 
ous doses of chlorate of potassium had been given. 

Chloroform. Morel-Lavallee f records three cases in which 
purpuric spots were formed under observation during the early 
stage of administration of chloroform by inhalation. 

According to Dudley Buxton, an erythematous eruption may 
follow both chloroform and ether, beginning as patches and be- 
coming diffuse on the neck and chest. It only lasts a few 
minutes. Probably purpuric spots are only an occasional out- 
come of this erythema. 

Cod-liver Oil is said by Lewin to have produced a vesicular 
eruption, and Farquharson speaks of its causing acne. 

Codeia. A widespread erythematous eruption ensued after 
this drug was given by V. Essen. ;£ The first attack was in spots, 
but on a second occasion a diffuse erythema all over the body 
followed a dose of 0.2 of a gram, or 3-10 of a grain. 

Copaiba produces in many people several forms of eruption, 
mostly of erythematous type, coming chiefly on the hands, arms, 
feet, knees, and abdomen. It may follow quickly on the first 

* Amer. Med. Record, July 21, 1883. 

\ Ann. de Derm, et de Syfih., vol. v. (1884), No. 2, p. 78. 

\St. Petersburg med. Woche?isch. y No. 17, 1894. 



DERMATITIS MEDICAMENTOSA. 485 

dose, or only after some quantity has been taken, and may be 
general or partial in its distribution. It fades rapidly if the drug 
is stopped, desquamation following only when the eruption is 
kept up by continued administration. The most common and 
characteristic rash consists of rose-colored, irregular patches, 
grouped or discrete, and only just perceptibly raised above the 
surface. In a case of my own the rash was exactly like scarla- 
tina, extending only down to the groins, while on the thumbs 
and forearms there were small vesicles or papules becoming 
vesicular. The eruption came out after taking six copaiba cap- 
sules in two days, and a fortnight later the same quantity had the 
same effect, but with the eruption even worse than before. Pro- 
fessor Neumann excised a part of the skin in such a case, and 
examined it microscopically. The papillary layer was normal, 
and the affection had its seat chiefly around the blood-vessels, 
the sebaceous glands, hair follicles, and sudoriparous glands, 
just in the same way as in measles. 

Urticaria and a miliary papular eruption have been observed, 
and Hardy describes a case where the first administration pro- 
duced rose-colored, elevated patches, and when again given after 
an interval, and taken for twelve days, a pemphigoid eruption 
ensued, with abundant secretion and desquamation, lasting six 
weeks, and resembling pemphigus foliaceus; anasarca, without 
albuminuria, was also present. Sequeira * reports a case which 
began with erythematous patches, and in a few hours large bullae 
appeared on the legs; eight capsules only had been taken. 
Copaiba imparts to the skin secretions a peculiarly disagreeable 
odor. 

Cubebs. One case is reported by Berenguier, where an 
electuary produced a general millet-sized, papular erythema, 
which coalesced into small patches in some places. It lasted 
two days, and was followed by desquamation. 

A combination of copaiba and cubebs, in a case of Mauriac's, 
led to a scarlatiniform and morbilliform eruption, succeeded by 
a central ecchymotic patch inclosed in two concentric circles, 
the outer a deep red, the inner pale rose color, the whole slightly 
raised. The ecchymoses were more marked on the lower 
limbs. 

* Brit, Med. Jour., vol. ii. (1899), p. 1108. 



, 



486 DISEASES OF THE SKIN. 

Digitalis. Traube is said by Behrend to have observed in one 
case a scarlatiniform and in another a papular erythema, after 
the ingestion of digitalis. Schuchardt also met with a universal 
papular eruption twice in the same person; and Morrow relates 
a universal erythematous eruption followed by giant urticarial 
plaques and a high temperature. Desquamation followed in 
large flakes, and complete shedding of the hair and nails. 
Friedheim describes papules of a dull red. 

Dulcamara. Erythematous, urticarial, and red scaly erup- 
tions have been observed. 

Ergot. Skin phenomena in connection with " ergotism " 
occur more frequently from eating ergoted rye in bread for long 
periods than from medicinal ingestion, but Meadows records 
two cases in which redness and swelling of the face and arm fol- 
lowed the administration of ergot on three occasions. 
Petechia?, vesicular, pustular, furuncular eruptions have been 
observed, and circumscribed gangrene where the peripheral cir- 
culation is weakest is well known. Frankenberg, quoted by T. 
C. Fox, in an endemic outbreak records bullae, miliaria, eczema, 
boils, urticaria, and loss of scalp, hair, and nails. 

Guarana. Fox quotes Mattegazza as describing urticaria 
from the use of guarana. 

Guaiacum. Murrell * described a miliary erythematous erup- 
tion very like a copaiba rash on the arms and legs with intense 
itching from this drug. 

Iodin and Iodids. — The eruptions that may be produced are 
pustular, vesicular or bullous, purpuric, erythematous, and urti- 
carial; and also anthracoid, sarcoma-like, vegetating, infiltrated 
plaques. 

The pustular eruptions are the most characteristic, and, like 
the bromid which they closely resemble, are discrete or con- 
fluent. The discrete lesions are, as a rule, much smaller than 
those of bromid; they are often simple pustules without any 
raised red base, and when they have one, are more acuminate 
* Philadelphia Medical Bulletin, January, 1891. 



DERMATITIS MEDICAMENTOSA. 487 

than those due to bromid. When confluent, they may be exactly 
like bromid lesions, and are called anthracoid by Besnier; or 
they may have clearer contents, tending more in the bullous 
direction than the bromid form. Confluent cases have been met 
with by Duhring, Da Costa, myself, and others, but they are 
much rarer than the corresponding bromid eruptions. There 
are always discrete lesions as well, in greater or less numbers, 
and the distribution, like the bromid rash, is chiefly on the face 
and limbs, especially round hair follicles. 

A further development of these confluent eruptions is seen in 
the so-called vegetating cases, in which an apparently papillo- 
matous condition is. developed. This papillomatous appearance 
is rare in iodid eruptions as compared with those of bromid, in 
which it may be often seen. It is not a true papilloma structur- 
ally, being mainly epithelial growth upwards, and subsides spon- 
taneously, but slowly, if the drug is discontinued. Norman 
Walker * reports a highly developed case from Unna's clinic, 
but with a single lesion on the nose. It was scraped away after 
only four days' observation. Hallopeau and Feulard have each 
recorded a case where true papillomatous development occurred 
on the cicatrices of an iodid eruption. 

In two cases of Pellizzari, quoted by Morrow, " there were 
large inflammatory nodular masses varying in size from a nut 
to a fist, seated in the subcutaneous tissue, accompanied by high 
fever, and followed by abscesses which left cicatrices." 

In Fordyce's case f the lesions became larger than a man's 
fist, but, unlike Pellizzari's, did not suppurate. These sarcoma- 
like lesions are possibly only extreme developments of cases like 
Pelizzari's. 

In Hutchinson's case % large red tumors, many of which broke 
down and ulcerated, appeared all over the body, limbs, and face, 
and killed the patient. Hutchinson thinks they are true sar- 
comata. 

The photograph § and history of a case were sent to me by 

* Lancet, March 12, 1892. He gives references to most of the previous 
cases. His histological examination is in the Monatsh. f. Derm., vol. 
xiv. 

\Jour. Cut. and Gen.- Ur. Dis. vol. xiii. (1898), p. 498. 

% Hutchinson's smaller Atlas, Plates III. and IV. 

§ The photograph from which I made the diagnosis is reproduced in 
Hutchinson's Archives, vol. xi., April, 1900, p. 160. Some other inter- 



488 DISEASES OF THE SKIN. 

Taylor of Liverpool, in which, in the course of three weeks, a 
copious crop of nodules of various sizes came out over the face 
and neck. The epidermis was tightly stretched over the 
nodules, which were hard and of the same color as the surround- 
ing skin. The outbreak was traced to Clarke's Blood Mixture, 
a quack medicine well known to contain iodid of potassium. 

In a case of Neumann's with advanced Bright's disease the 
nodules broke down into crateriform ulceration, and post- 
mortem extensive ulceration of the pyloric region of the stomach 
was discovered. In the case of a doctor, whom I saw with Col- 
cott Fox, there were red infiltrations, firm to the touch, raised 
about one-eighth of an inch above the surface, and situated on 
the back of the hands and wrists; judging by the plate and de- 
scription it was very similar to the bromid lesion described by 
Pini. 

Vesicular and bullous are much rarer than pustular eruptions. 
John O'Reilly, and later Bumstead, were the first to call atten- 
tion to them ; Tilbury Fox * described two cases ; and Nevins 
Hyde,f after recording a case, gives the bibliography up to date 
of this form. Hyde quite correctly stated that there are pseudo- 
bullous and truly bullous types. 

The pseudo-bullous is probably the more common form. It 
begins as papules, and in most of the cases the vesicular or bul- 
lous part is seated on a solid base, and the bullous character is 
more apparent than real. In a case of Duckworth, which looked 
herpetic, no fluid escaped on puncture; and one of my own, 
which to the eye was bullous, J; proved to be solid on puncture, 
a drop of clear fluid only escaping on pressure. In one of my 
cases of this form the eruption was limited to the buttocks. 
Duckworth also observed in one case that, as in the bromid rash, 
the lesion was seated on scar tissue. 

In Lindsay's case, in the Belfast Hospital, after only seven 
and a half grains, the patient had headache, nausea, severe itch- 
ing, and an outbreak of bullae, surrounded by two concentric 

esting cases are also there recorded. In one there were elevated soft 
bluish-red nodules from a pea to an olive in size, with an erythematous 
blush round them. 

* Clin. Soc. Trans., vol xi. p. 40, with colored plate. 

f Amer. Arch, of Derm. , vol. v. p. 333. 

X Author's Atlas, Plate XXXVI. 



DERMATITIS MEDICAMENTOSA. 489 

rings, the outer as large as a crown piece; the trunk, upper limbs, 
and face were thickly covered, while the lower limbs were almost 
free. 

In Hallopeau's case bullae with purulent thickish contents 
came out on the mucous membranes of the tongue and con- 
junctiva as well as on the face and arms; subsequently condylo- 
matous vegetations appeared, and cicatrices with bands were 
left. He has had another case since. * Taylor also records 
three cases in which vegetating lesions came on the site of the 
bullae. 

What Hutchinson f calls iodid hydroa is a more distinctly 
bullous eruption. I had a somewhat similar case, in which 
bullae came out thickly over the face and arms, but each had a 
rather broad red areola, and there was considerable swelling of 
the face. A very severe case, which hastened the patient's end, 
is recorded by Morrow \% and another case, fatal in eight days 
after thirty grains of the iodid in divided doses, is recorded by 
Wolf of Goritz,§ in which there were papules, pustules, and bullae 
in the face and all the visible mucous membranes. I saw a well- 
marked case affecting the face especially, which was sent into 
hospital as a case of smallpox. In Wolf's, Morrow's, and my 
cases, there was renal and cardiac disease. 

Mayer examined the contents of a bulla and found a little 
iodin in combination with an alkali, while the urine was free. 
O. Rosenthal || found increase of eosinophiles, staphylococci, 
and diplococci, and Sabouraud's micro-bacillus. 

Erythematous Eruptions. — Patches may occur on the face, fore- 
arms, and chest. 

A papular erythema after small doses is recorded by Maieff 
of St. Petersburg. 

Diffuse erythema has occurred: one case, a woman, aet. fifty, 
is reported by B. A. Rugg.*~ After taking four grains every 

* " Une forme necrotique bulleuse et vegetante d'eruption iodique," 
Hallopeauet Fouquet, Annates de Derm.^ vol. ii. (1901), p. 541. 

\Syd. Soc. Atlas, Plate XXXIII. 

J Morrow, Amer. Jour. Cut. and Gen.-Ur. Dis. t vol. iv. (1886), with 
colored plate. 

§ Berlin klin. Wochensch., quoted in Lancet, October 23, 1SS6. 

\Archiv f. Derm. u. Syfth., vol. lvii. (1900), p. 3. Colored and histo- 
logical plates and numerous references. 

\ Lancet, June, 1879. 



49© DISEASES OF THE SKIN. 

four hours for some days, large red papules, with a shotty feel, 
came on the wrists and forearms, and from this a uniform 
erythema, followed by free desquamation, spread all over the 
body. 

Berenguier described a scarlatiniform eruption on which small 
discrete vesicles developed. 

Urticaria is also exceptional. Jordan Lloyd had a case in 
which a dose of three or four grains produced general urticaria 
in three hours, which was gone by the next day. Taylor of New 
York showed a case in which the urticaria was limited to the ex- 
posed parts, and on the second day clear vesicles came out 
round the wheals. Pellizzari had several cases with urticaria 
and papular erythema, phlyctenular with purulent contents de- 
veloping on some of the wheals. Other similar cases are on 
record. 

Of similar nature are the cases of edema following iodids. It 
may occur in the orbit, or even in the glottis, of which Groe- 
now * collected nine cases. Dyspnea, requiring tracheotomy 
for its relief, may ensue. 

Erythema Nodosum. — Indurations, with or without reddening 
of the skin over them, or in the latter case very like erythema 
nodosum, may occur after iodids as well as bromids. In a case 
sent to me by my colleague, Raymond Johnson, there were sub- 
cutaneous oval ill-defined tumors over the ribs, over two inches 
long, firm, and the skin over them was normal. 

An eruption like erythema nodosum is reported by Talamon, 
but it was on the buttocks, front of the thighs, the calves, and 
on the back, and there were none of the ensuing ecchymotic dis- 
colorations characteristic of erythema nodosum. Pellizzari, \ 
Ricord, and Fischer have also reported similar cases. Other 
differences are pointed out under Bromid Eruptions. 

Purpura has been recorded several times by Silcock, Stephen 
Mackenzie, C. Fox, E. Vidal, Besnier, Fournier, and others. In 
Mackenzie's case the child died from it after a single dose of 
two and a half grains. In Silcock's case the purpura disap- 
peared under arsenic, and returned when that was left off; the 
limbs were especially affected. Hemoptysis and metrorrhagia 
have also occurred (Kness). It has been noted in the mouth 

*Abs. Brit. Med. Jour., May 10, 1890. 

f Abs. Ann. de Derm, et de Syph., vol. vi. (1885), p. 573. 



DERMATITIS MEDICAMENTOSA. 4g i 

with and without skin purpura. According to Besnier purpura 
does not occur from iodin itself, only from iodid of potassium. 
In Arnozan's case bullous lesions with severe general symptoms 
first appeared, and left papillary growths on the cheeks, and was 
followed by purpuric patches on the buttocks and legs and urti- 
caria on the fingers. 

In Tom Robinson's case, a man of sixty-three, a grain of iodid 
three times a day produced purpura in a week. 

Gangrene has supervened occasionally on other forms of iodid 
eruption; thus in O'Reilly's case of bullous iodid rash, the parts 
on which the bullae had been, sloughed, the entire penis being 
lost. 

Erythema-like lesions sometimes occur, of which I have seen 
one marked instance. 

Iodid of potassium has sometimes aggravated pre-existing 
eruptions for which it has been unsuitably prescribed. I have 
several times seen such an aggravation of acne rosacea, the 
eruption suppurating more freely than usual and extending be- 
yond its usual boundaries. It is a dangerous drug in bullous 
eruptions. 

A case of dermatitis herpetiformis under my colleague, R. W. 
Parker, was aggravated into a gangrenous condition by its use. 
Iodid, like bromid eruption, has occurred in suckling infants 
whose mothers were taking the drug. 

Thin examined a bullous iodid eruption in a case under Howard Marsh. 
The sebaceous glands were unaffected, but the vessels were diseased and 
plugged with disorganized blood. The bulla, he considers, is due to an 
injury to the walls of a blood-vessel at a limited spot, which allows of the 
escape of blood constituents; when the injury is slight, iodin acne is 
produced; when more severe, bullous and pustular eruptions, and in the 
worst form, hemorrhagic extravasations. 

Vincent Harris* also examined a pustular eruption in one of Duck- 
worth's cases, and regarded it as a localized superficial dermatitis, in 
which the hair follicles and sweat glands were unaffected: the vessels 
were numerous, dilated, and sheathed with exudation corpuscles; the 
effusion was greatest in the papillary layer, which was flattened out and 
excavated. 

I have also examined a small lesion from an extensive pseudo-bullous 
eruption (my Atlas case). While Harris' observations are true in the 
main the hair follicles do not always escape, as the woodcut clearly 
demonstrates, and as may often be seen during life; at the same time, 

* Path. Trans., vol. xxx. (1879), p. 476. 



49 : 



DISEASES OF THE SKIN. 



neither they nor any other structure are essential to the process, which is 
mainly in the papillary layer. The lesion is a solid one; there is no 
vesiculation in the rete, as the clinical appearances suggested. 

Leredde and Pini found numerous eosinophile cells; they are not only 
in the deeper parts of the infiltrated area, but also in the rete Malpighii, 
and epidermis (Rosenthal *). Rosenthal also noted extravasation of blood. 




Fig. 27. — An iodid eruption which looked like a vesicle, but proved to be 
solid, consisting of enormous cell effusion in the papillary layer with 
a hair follicle in the center, and the sebaceous gland unaffected. 



Iodid and bromid eruptions, especially the severer forms, are 
very liable to occur where there is any renal inadequacy, whether 
that is due to disease of the kidney itself, or to a weakly acting 
heart. This helps to explain the circumstance that iodid erup- 
tions often do not come out until the drug has been stopped for 
some days, or even two weeks. Iodid of potassium is a power- 
ful diuretic, and as long as diuresis is kept up, unless the dose is 
* Archiv f. Derm. u. Syfth., vol. lvii. (1901), p. 7, Plate III. 



DERMA TITIS MEDICAMENTOSA. 



493 



very large, there is often no eruption, but when the drug is 
stopped, after a few days the diuresis stops, and the iodin, not 
being removed fast enough, excites an eruption. 

Diagnosis. — This is much the same as for the bromid rashes, 
but the lesions are more frequently partially bullous. The dis- 
crete pustules are smaller than those of bromid or ordinary 
acne, and are often simple pustules, with a red areola, but no in- 
duration. 

Treatment. — The same as for bromid eruptions, with the addi- 
tion of diluents, such as barley water, freely administered. 

Iodoform. Iodoform is rarely given internally,* but when ab- 
sorbed from wounds or other surfaces, eruptions and serious 
general symptoms have occurred. Jadassohn, from his own 
observations, believes that in all cases the drug must also come 
into contact with the sound skin; and even in Raynaud's and 
Herzfeld's cases, where absorption apparently occurred by the 
vagina and urethra respectively, suggests that the skin may have 
received some of the drug; he cites three cases in which a 
mucous membrane was immune to iodoform, while the skin 
reacted. Eruptions from its directly irritant action on the sound 
skin are far more frequent, chiefly in persons who have a special 
idosyncrasy towards the drug, which may be congenital or ac- 
quired. 

The eruptions from absorption are erythematous, urticarial, 
or purpuric. The erythematous may be 'diffuse and bright red 
(Zeissl) or finely papular. In a case of iodoform absorption 
under Marcus Beck,f a punctiform rash was observed on the 
arms, knees, and dorsal surface of the feet. Janovsky of Prague 
also reported a case at the Copenhagen Congress. Treves J re- 
ports a case in. a child, in the form of closely packed minute 
papules on an erythematous base from half to one inch across. 
It was interesting because it developed three days after the sub- 
sidence of a local irritant dermatitis from the application of 
iodoform to a wound. Hoepfl has only observed small red 
spots over the whole body from its application to a wound. 

* Zeissl gave it in a considerable number of cases, but never saw a rash 
from it. 

f Brit. Med. Jour. , June 17, 1882. 

% Practitioner, vol. xxxvii., No. 4, October, 1886, with bibliography. 



494 DISEASES OF THE SKIN. 

Zeissl had a case with urticaria nodules following the application 
of iodoform pencils to a sinus. 

Purpura has been observed by Jennings, Janovsky, R. W. Tay- 
lor, and others. In Jennings' * case grain doses in capsule had 
been given. That serious general symptoms of nocturnal de- 
lirium, elevation of temperature, drowsiness, and progressive 
emaciation, or even simulated meningitis, may follow from its 
absorption is well known. Death has occurred in some cases. 

The eruptions due to the local irritant action of iodoform may 
be in the form of diffuse erythema with edema, resembling ery- 
sipelas sometimes, or it may go on to a violent vesicular or bul- 
lous eruption, but more frequently presenting an eczematous 
appearance. Neisser describes eight cases of eczematous 
eruption following its use, commencing w T ith deep redness with 
severe itching and burning, followed by the development of 
vesicles. Like other forms of irritant dermatitis, the eruption 
is not always limited to the site of immediate application, and 
especially is this the case in surgeons, who, having once suffered 
from it, show an increased susceptibility to it, until at last even 
the smell is sufficient to excite an eruption, as in Koster-Sykes' 
own personal experience. Handling iodoform gauze has pro- 
duced violent vesicular dermatitis repeatedly, as Hancocke 
Wathen f records. A number of cases are reproduced in Fox's 
note to Morrow's article. These eruptions are often not dis- 
tinguishable from a vesicular eczema, but the more violent the 
inflammation the more likely is it to be due to an irritant. 

Lactophenine. Large erythematous plaques on the face, 
with swelling of the upper lip and a pea-sized bulla and small 
blood-stained ulcerations on its inner surface, preceded by heat 
and pricking of the head, and later intense headache, shivering, 
and fever. These were the symptoms observed by A. Haber J 
in a woman of fifty, who took twelve grains in a day. 

Mercury. Although it was denied by Hebra, it must be ad- 

* Amer. Jour. Cut. and Gen.-Ur. Dis., vol. vi. (1888), p. 175. See also 
R. W. Taylor, New York Med. Jour., October 1, 1887; Meunier, " These 
de Paris," 1889: and M. L. Raynaud, Annates de Derm., vol. vi. (1895), 
p. 227. 

f Brit. Jour. Derm., vol. x. (1898), p 95. 

% Correspondent Btattf. schweizer Aerzte, vol. for 1897, p. 742. 



DERMATITIS MEDICAMENTOSA. 



495 



mitted, on the authority of Fournier * and Hallopeau, Engel- 
mann, and others, to say nothing of older writers like Alley, that 
erythematous eruptions may arise from its internal administra- 
tion, while the so-called mercurial eczema from its inunction is 
well known, and is of the same character as that due to any 
other irritant, but with a great tendency to generalize. 

Universal exfoliative dermatitis from mercurial inunction has 
already been alluded to under Dermatitis, and it has also oc- 
curred after a sublimate dressing (Eudlitz). Exfoliation of 
nearly the whole of the horny layer without erythema has also 
occurred (S. Taylor). The eruption from ingestion may be par- 
tial or general, is diffuse, deep red, accompanied by swelling, and 
may easily be mistaken for erysipelas, especially as it begins in 
the face, and the surface is smooth, shining, and itchy. It may 
extend over more or less of the body. It may be papular or 
scarlatiniform, as in the case of Robinson of Constantinople, and 
in Hallopeau's case a single dose internally or externally pro- 
duced a scarlatiniform rash, followed in two weeks by abun- 
dant desquamation: after two and a half grains of calomel, 
miliary vesicles followed, which developed into pustules. In 
Ramally's case it followed two mercurial inunctions, while no 
rash followed an injection of mercurial oil; in Lessing's case gen- 
eral scarlatiniform erythema ensued on a hypodermic injection 
of calomel; hypodermic injections of yellow oxid of mercury 
(Petersen), and thymol mercury have also been followed by 
erythematous eruptions; but Janovsky found that injecting pure 
paraffin oil produced the same rash as the thymol mercury in the 
same patient. 

Guelpa met with a papular eruption on the face and limbs from 
using a vaginal douche of a half per cent, solution of corrosive 
sublimate. Petrini had a case of bullous eruption in a woman 
of twenty-two after an intra-uterine injection of the perchlorid. 
She was intolerant of mercury in any form. In Mouflier's case 
it followed vigorous mercurial and belladonna frictions. In 
Blanchon's case a general roseolous eruption followed exposure 
to the fumes of mercurial vapor. Therefore the evidence goes 

*See also L. de Saint-Germain, two cases, Ann. de Derm, et de Syph., 
vol. i. (1890), p. 657. There is a good abs. of Morel-Lavallee's paper 
in Brit. Jour. Derm., vol. iii. (1891), p. 395. Also Berlin Inter. Cong. 
Jadassohn's paper, loc. cit., gives many interesting cases. 



496 DISEASES OF THE SKIN. 

to prove that in the case of mercury these eruptions may follow 
in certain people whatever may the mode * in which the drug 
enters the body. This is corroborated by a case of Biirtzeff,f in 
which a papular eruption followed an inunction, a hypodermic 
injection, and a single dose internally, the mercurial prepara- 
tion being different each time. General symptoms of mercurial- 
ization may or may not be present. The above do not exhaust 
the possibilities of the form the eruption may take; urticaria, 
purpuric, and ulcerative eruptions occur. 

Morphia. A bright erythematous eruption, attended with 
severe itching and pricking, has followed the ingestion of 
morphia or opium, in many instances. Cases have been re- 
ported by Ringer, Farquharson, C. Fox, and others. As a rule 
it is papular, and resembles measles, but the papules vary in 
size, and sometimes the eruption is scarlatiniform, or the minute 
papules may be crowned with minute vesicles. Steinboehmer 
records a vesicular eruption, and Kirn J describes even small 
bullae, with intense itching of the perineum and scrotum after a 
suppository; Mobius from the same cause saw general erythema 
and urticaria. Multiple ulcerations occurred in Surroville's 
case. Trousseau considers the sweat orifices to be the site of 
the lesions. Very free desquamation of the whole area often 
ensues. 

These eruptions are much more frequent after ingestion of 
the drug than after hypodermic injections, but a scarlatiniform 
eruption was produced by a hypodermic injection by Comanos. 
Inflammation, urticaria, pustules, and abscesses at or near the 
site of injection are not rare, and are probably due to the nozzle 
not having been made aseptic before use, or from the acid used 
to dissolve the morphia. Opium and laudanum eruptions are 
of similar characters when produced by taking the drug, but 
opium is also a local irritant to some. In a morphinomaniac 
injector § there was intense irritation of the skin, and indurated 
scaly patches developed where the scratching was most severe. 

* On the other hand, several cases like Ramally's are known, in which 
inunction produced a rash, while none ensued when given by the mouth, 
and in another subcutaneous injection produced no rash, although inunc- 
tion had done so. See Jadassohn, loc. cit. 

f Burtzeff. Abs in Brit. Jour. Der7n., vol. iii. (1891), p. 396. 

% Wien. med Presse, No. 18, 1883. 

§ Private Notes, J., p. 692. 



DERMATITIS MEDICAMENTOSA. 



497 



Phenacetin. Valentin * reports a case where fifteen grains 
produced in two hours flushing, and next day a general acumi- 
nate and flatly papular erythematous rash, most marked on the 
limbs. 

Phenyl hydroxylamin. f A student spilt an alcoholic solution 
of this drug on his clothing, over the abdomen and thighs; 
in a few minutes he became comatose and pulseless. The lips 
and mucous membrane of the mouth were gray-blue, the skin of 
the extremities intensely blue, while other parts looked cadaver- 
ous. There were also reddish-brown spots which did not dis- 
appear on pressure, on the hands, thighs, and abdomen. Blood 
when drawn off was chocolate brown, due to the hemoglobin 
having been converted into methemoglobin. Nitro-benzole 
poisoning produces similar effects. Drawing off some of the 
blood and intravenous injection of a liter of 3 per cent, chlorid 
of potassium, followed by .4 bicarbonate of potassium, saved his 
life. 

Phosphoric Acid. Hasse records the occurrence in a girl of 
a bullous eruption like pemphigus from this drug. The erup- 
tion disappeared when the medicine was stopped, and recurred 
when it was resumed. Phosphorus has produced purpura, but 
only in a poisonous dose. 

Quinine. — The eruptions due to quinine, and occasionally to 
other cinchona preparations, are multiform in character, and 
vary much in severity. They are rather rare, considering how 
frequently the drug is administered. An eczematous eruption 
is not infrequent among the workmen in quinine factories, ap- 
parently due to external contact. Morrow analyzed 60 cases 
from internal administration, and found 38 erythematous, 12 
urticarial, 5 purpuric, 2 vesicular and bullous eruptions. Erythe- 
mato-bullous and other lesions are on record. They are more 
frequent in women, but the only cause assignable is idiosyn- 
crasy, for although more common where the dose has been large 
or frequently repeated, a single dose of a grain or a grain and a 

* Valentin, Theraft. Monatsh., July, 1888, p. 330. 

f Hirsch and Edel, Deutsch. median. Wochensch., October 14, 1895. 
Abs. in Lancet, November 16, 1895, p. 1261. 

32 



498 DISEASES OF THE SKIN. 

half has several times been sufficient to produce a rash, and in 
one, half a grain produced an erysipelatous rash on one side of 
the face, which lasted twelve hours (W. Newman), while Burney 
Yeo * experienced an extensive erythema on the legs four hours 
after a single dose of a quarter of a grain. 

In C. W. Allen's \ case the idiosyncrasy was acquired, and 
here also a quarter of a grain would excite an eruption, while by 
varying the dose the eruption, " primarily erythematous, be- 
came urticarial, edematous, bullous, covered with small vesicles 
or converted into an excoriated patch." Moreover, he could 
produce an eruption whether the drug was given by the mouth 
or rectum, subcutaneously, or by ointments, or by the patient 
holding the drug in the mouth for a few minutes. 

Stelwagon's J case a * present holds the record, the patient had 
had a score of attacks; 1-16 of a grain by the mouth, a dentrifice 
containing a small proportion of calisaya bark, and a quinine 
hair-wash were all equally efficacious in producing, in a few 
minutes, a hot flush over the whole body, soon followed by a 
copious and universal scarlatiniform eruption, and this again by 
desquamation. 

The erythematous form varies. As a rule, it is a scarlatini- 
form efflorescence, beginning on the face and neck, and spread- 
ing all over; or it may be partial, but symmetrical in its distribu- 
tion. Sometimes the lesion is more distinctly papular, the 
papules being minute and acuminate or convex and morbilli- 
form; even when more distinctly urticarial the wheals are more 
often pink than white. All these forms are attended with severe 
itching and pricking, and may be preceded and accompanied by 
considerable constitutional disturbance, nausea, vomiting, a rise 
of temperature even up to 102 F., and a pulse of 130 or 140. In 
one case there was severe dyspnea with large wheals (Floyer). 
The general erythematous eruptions are, unless transitory, fol- 
lowed by desquamation, which may be very copious, casts of the 
hands and feet being thrown off, and sometimes the exfolia- 
tion persists for several weeks or even two months (K6bner).§ 

* Brit. Med. Jour., March 16, 1889. 
\ N. Y. Medical Record, January 26, 1895. 
$ Stel wagon, Amer. Jour. Cut. Dis., vol. xx. (1902), p. 13. 
§ An extreme case is recorded with illustrations by Lanz of Moscow in 
the Monatsk., vol. xvi. p. 309. 



DERMA TIT IS MEDICAMENTOSA. 



499 



Some think that desquamation may be produced without ante- 
cedent eruption, but this is highly improbable. In Neumann's 
case the desquamation after the efflorescence lasted several 
weeks, and many abscesses and furuncles ensued. 

In a case of Nunn of Savannah the erythema was in bright red 
patches, one inch in diameter, and almost unilateral, occupying 
the left side of the nose, cheek, and chin, flexure of left wrist, 
back of hand, and knuckles of fourth and fifth fingers; and in an- 
other case it was on the palms and face. In Ruyssen's case the 
patches were only on the extensor aspect of the limbs, very 
variable in size and shape, and mingled with them were small 
papules. 

In several cases severe inflammation about the genitalia has 
occurred. In Schuppert's case, after six-grain doses, intense in- 
flammation, with commencing gangrene of the scrotum, ensued. 
In Briquet's case an ecchymotic patch on the buttocks became 
gangrenous; and in Kobner's case there was an erysipelatous 
eruption of the scrotum. Purpura of the usual characters has 
followed quite moderate doses ; a grain and a half taken for four 
days produced it in Gaudet's case. 

Vesicular eruptions are less common than any of the above. 
Heusinger * had a case in which there was a vesicular eruption 
like herpes, and Panas saw an eruption like the bullae of pemphi- 
gus after large doses. It may also be vesiculo-pustular. 

In Hagan's + case a child of four and a half suffered from an 
erythematous eruption for three years without the cause being 
suspected, the mother having been in the habit of dosing the 
child with quinine to prevent its taking cold. 

The diagnosis can only be made from similar eruptions due to 
other causes, by knowing that the patient has taken quinine, and 
excluding other factors; in many cases there is a history of pre- 
vious attacks under, similar circumstances. From scarlatina, 
the constitutional symptoms will generally assist in the differen- 
tiation, and there is often in the erythema a sharp line of demar- 
cation from the normal skin contrasting with it, while that of 
scarlatina is never defined at the border. 

The treatment is simple and effectual. Withdraw the drug, 
and use locally soothing astringent lotions, such as calamin or 

- Quoted by Bergeron and Proust. 

f Xeiv York Med. Jour., March 28, 1891. 



5°° 



DISEASES OF THE SKIN. 



subacetate of lead; the addition of liq. carbonis detergens, fT^x to 
the 5j, assists in allaying the itching. Sometimes a saline pur- 
gative may be given with advantage. 

Resin. " About as much as two walnuts " produced in a 
woman swelling of the face, followed by an urticaria, with small 
wheals on the chest and arms (Jacob).* 

Rhubarb. Litten f met with a case of severe hemorrhagic 
and pustulo-bullous eruptions from §iij of infusion of rhubarb 
with bicarbonate of soda. Goldenberg had also a case with 
purulent bullae. In Kiitur's case there was a " general des- 
quamative recurrent scarlatiniform eruption both from rhubarb 
and from ipecacuanha." 

Salicylic Acid, its salts and derivatives, salicin, salipyrin, 
salol, etc., produce eruptions in a rather large proportion of 
cases, the salicylate of soda being the most frequent offender, 
partly, but not entirely, because it is more frequently given than 
the rest. These drugs act primarily on the vaso-motor centers, 
and the eruptions may be scarlatiniform, morbilliform, or urti- 
carial, less frequently vesicular, bullous, or purpuric. A rise of 
temperature, J sweating, and edema are frequent concomitant 
vaso-motor phenomena. 

Salicylate of Soda. Erythematous eruptions following the 
ingestion of this drug have been so frequently recorded that 
special references are unnecessary in the majority of cases. 
They are scarlatiniform in character, and may thus give rise to 
some difficulty in diagnosis, especially when the mucous mem- 
branes are affected, but they would not develop exactly like 
scarlatina, as they may commence in any part of the body, and 
often the rash is not uniform in its characters. Morbilliform, 
patchy, and diffuse erythema, often with much edema, are less 
common. Urticaria is not very common. A very severe case 
is recorded by Shepherd § of Montreal. A man with supposed 

* Jacob, Med. Press and Circ, March 3, 1880. 

\ Supplement, Brit. Med. [our., May 21, 1891. 

% A temperature of 107 F. is recorded by Barron, Lancet, May 31, 1890. 

% Arner. Jour. Cut. and Gen. -Ur. Dis., vol. xiv. (1896), p. 16. 



DERMA TITIS MEDICAMENTOSA. 



5oi 



acute rheumatism, after taking three twenty-grain doses, devel- 
oped an urticaria beginning on the lower extremities, becoming 
general by successive crops, involving even the mucous mem- 
branes. The wheals soon became hemorrhagic, and many of 
them sloughed, leaving slowly healing ulcers. Blebs also ap- 
peared on some of the lesions. 

Bullous eruptions have been observed several times. Rosen- 
berg * records a bullous eruption which ensued several times 
after the administration of the soda salt, and was kept up as long 
as there was any salicylic acid in the urine. A case of extensive 
pemphigus in acute rheumatism in a boy of sixteen, reported by 
Bayliss,f was probably due to the salicylate of soda. A cir- 
cinate erythemato-vesicular eruption, apparently like a derma- 
titis herpetiformis, was experimentally proved to be due to this 
drug by E. Beier. \ 

Salicin produces eruptions usually erythematous, like those 
from salicylate of soda, but far less frequently. 

Salicylic Acid. Heinlein § observed a case in which, when 
the dose was raised to gr. 60, itching and tingling of the skin 
were produced, followed by diffuse redness of the left side of the 
face, the right side of the chest, and both lower limbs, with slight 
edema of the eyelids, upper lip, and lower limbs, and a rise of 
temperature to 101.8 F. and a pulse of 90. After an interval 
the same dose was repeated; in a quarter of an hour severe 
burning pain was felt, and in half an hour severe general urti- 
caria ensued, but was gone by the next day. Small doses could 
be taken with impunity. 

In Wheeler's || case there were vesicles and pustules on the 
hands and feet, with much sweating, which ceased when the drug 
was stopped. Freudenberg ^[ observed large petechias and 
vibices, followed in a week by profuse desquamation. The repe- 
tition of the drug after an interval produced the same result. 

* Deutsch. med. Wochensch., 1886, No. 33. 

f Lancet, August 19, 1893. Other cases are quoted in Neale's " Digest," 
and Morrow's " Drug Erup.," p. 410, Syd. Soc. Ed. 

% Archivf. Derm. u. SypJi., vol. xxviii. (1894), p. 125. 

% Rundschau, Bd. 19 (1878), Heft. 10. Urticaria is also recorded in 
Practitioner for February, 1879. 

|| Boston Med. and Surg. Jour., October 17, 1878. 

1" Alljr. med. central Zeitung y October 26, 1878. 



5 o2 DISEASES OF THE SKIN. 

Salipyrin.* In a man of sixty-six with old nephritis, after 
four fifteen-grain doses an infiltrated red edema of the scrotum 
was produced. The repetition of the drug led to necrosis of the 
affected areas. A. Bruck f observed in himself an eruption after 
a single gram dose. The characters of the rash were those of 
antipyrin, to which the author had previously shown himself to 
be hypersensitive; on the glans penis the rash was vesicular. 

Salol. Demme J observed urticaria in a child after its internal 
use, but such an occurrence is quite exceptional. Violent der- 
matitis has ensued from its topical use (Morel-Lavallee). 

Santonin. Urticaria developed in a child shortly after tak- 
ing three grains of the drug for supposed worms. It subsided 
in a couple of hours, after a warm bath (Sieveking.). § 

Silver Nitrate. Long-continued administration is well known 
to produce slate-colored pigmentation (see Argyria). 

Stramonium produced an erythematous eruption in a case of 
Deschamps. || 

Strychnia. A quarter of a grain of quinine three times a day 
having produced after the second dose a scarlatiniform rash, 
1-24 of a grain of strychnia was given instead, and the same 
kind of rash appeared (Skinner fl). Diefbach accuses strychnia 
of producing pruritus and miliaria. 

Sulphonal. Leloir describes a diffuse erythematous and 
macular eruption like a syphilitic roseola, chiefly on the trunk. 
Schotten and Engelmann report a diffuse scarlet eruption, one 
on the thighs, the other on the breasts; while Bresslauer has 
seen purpuric patches on the limbs. The urine after toxic doses 
is brownish-red, due to the presence of hemato-porphyrin. Wol- 
ters reports two cases, one with a scarlatiniform, the other with 
a vesicular eruption. 

*F. Schmey, Ther. Monatsch., 1897, Heft. 3, p. 175. 

f A. Bruck. Abs. Brit. Jour. Derm., vol. xiii. (1901), p. 196. 

%Brit. Med. Jour., Paris corr. December 22, 1888. 

§Brit. Med. Jour., February 18, 1871. 

I Gazette des Hopitaux, 1878, No. 124. 

T Brit. Med. [our., January 29, 1870. 



DERMATITIS MEDICAMENTOSA. 503 

I know of a patient who has taken the drug nightly for fifteen 
years without ill effect. 

Tannin.* General urticaria followed the topical application 
of a one to fifteen solution of tannin to the pharynx in a case 
under the care of Lange of Copenhagen. 

Tar. When absorption occurs from its vigorous inunction 
over a large surface, shivering, fever, nausea, vomiting, and 
diarrhea may ensue, with olive-green urine, black vomit and 
feces. On the skin itself tar may also act injuriously; in some 
people a very moderate external use will produce swelling, red- 
ness, heat, and pain, and sometimes itching; vesicles and bullae 
may form; also " tar acne," or inflammation of the hair follicles 
or sebaceous glands, from plugging of the orifice, producing 
papules or nodules with a black central spot; in a few case these 
papules break down and ulcerate. The application of the tar 
must be stopped at once on the occurrence of such symptoms, 
and free diuresis, produced by copious draughts of barley water, 
will often prevent or soon remove them. 

\Yaldeck j records that an erythematous eruption occurred in 
a patient who was taking Guyot's tar capsules. Carbolic acid 
absorption from a Lister's dressing produced an " erythema 
urticatum " in one case (Zeissl). 

Terebene. O. H. Garland | reports that after six five-minim 
doses a profuse, bright red, intensely itching, papular rash was 
produced, first on the left hand, with much swelling, and then on 
both ankles, extending on the legs up to the knees. In the same 
patient, thirty years previously, a turpentine liniment produced 
a similar rash, with much swelling of the arm. Lascelles Scott 
experienced a similar rash, but ascribed it to the impurity of the 
terebene. 

Toxin or Serum Eruptions. The subcutaneous injection of 
various toxins or anti-toxins, such as tuberculin, diphtheritic, 
anti-streptococcic serums, and others, is not infrequently at- 

* Brit. Med. Jour., May 10, 1890, from Deutsch. med. Wochensch., 
January 2, 1890. 

\ Deutsch. med. Wochensch., iv. , 1879, No. 9. 
\ Lancet, May 22, 1886. 



5°4 



DISEASES OF THE SKIN. 



tended with the development of erythematous eruptions, scarla- 
tiniform, morbilliform, patchy, or diffuse. Urticaria is also fre- 
quent. As a rule, these eruptions, to which only a certain num- 
ber of people are liable, recur after each injection, but not always 
in the same form. There is little or no itching, but there may be 
desquamation. There is nothing distinctive about these rashes. 
The form, and indeed the very occurrence, depends on the 
idiosyncrasy of the individual, so that the vaso-motor centers 
are abnormally easily affected by these toxins, and the diagnosis 
is only made by the knowledge that a toxin has been injected. 
According to Dubreuilh, the serum of the horse is liable of itself 
to produce an eruption, and he suggests that other animals 
should be selected for anti-diphtheritic serum. 

Turpentine has been followed by an erythematous redness, 
chiefly of the face and upper part of the body, minute papules, 
and sometimes vesicles, with intense itching, developing in some 
cases. In one case minute acuminate papules, like shagreen, 
with violent itching, extended all over the body, the itching con- 
tinuing after the rash had gone. In another a bright red morbil- 
liform eruption was produced by a teaspoonful of turpentine 
given to a child with diphtheritic croup. Feibes reports a conical 
papular eruption due to it. 

The forms of eruption and the drugs that produce each are 
placed together in the following enumeration: 

Erythema. Arsenic, antipyrin, belladonna, benzoate of soda, 
boric acid, borax, bromin, cantharides, capsicum, chinolin, 
chlorate of potash, chloral hydrate, chloralamid, chlorate of 
potassium, chrysarobin, codeia, copaiba, cubebs, digitalis, dulca- 
mara, guiacum, iodin, iodoform, lactophenine, mercury, morphia, 
phenacetin, quinine, salicylic acid, stramonium, strychnia, sul- 
phonal, tar, tartarus boraxatus, terebene, toxins, turpentine. 

Vesicular. Antipyrin, arsenic, cannabis indica, chloral, cod- 
liver oil, copaiba, iodin, morphia, quinine, salicylic acid, sul- 
phonal, turpentine. 

Bullous. Antipyrin, bromin (one case), cannabis indica, 
copaiba, chloral, iodin, mercury, morphia, phosphoric acid, qui- 
nine, rhubarb, salicylates. 



DERMATITIS MEDICAMENTOSA. 505 

Urticarial. Antipyrin, arsenic, bromin, copaiba, dulcamara, 
guarana, iodin, iodoform, quinine, resin, salicylates, santonin. 

Pustular. Arsenic, bromin (confluent), chloral, iodin (iso- 
lated), salicylic acid. 

Purpuric. Antipyrin, arsenic, chloral hydrate, chloroform 
inhalation (early stage), ergot, iodids, idoform, quinine, salicylic 
acid, sulphonal. 

Pityriasis Rubra. Bichromate of potash, mercury. 

Psoriasis (?). Borax, bichromate of potash. 

Eczema. Bromin (Voisin), borax, chrysarobin, bicarbonate of 
potash, iodoform. 

Gangrene. Arsenic, ergot, iodid, quinine (one case). 

Keratosis. Arsenic. 

Persistent Desquamation. Quinine. 

Abscess. Quinine. 

Furuncles. Arsenic, bromin, quinine. 

Anthracoid. Bromin, iodin. 

Ecthyma. Bromin. 

Zoster. Arsenic. 

Cyanosis. Antifebrin, exalgin, monobrom-acetanilid, phenyl- 
hydroxylamin. 

Pigmentation. Arsenic, nitrate of silver, picric acid. 

Sarcoma-like. Iodin. 

On reviewing these various drug eruptions, the number which 
produces some sort of erythema is very striking. Excluding 
those which, like nitrate of silver, merely produce discoloration, 
there are forty-eight; out of these, thirty-seven produce ery- 
thema, and of the other eleven, three excite urticaria and four 
vesicular or bullous eruptions. 



506 DISEASES OF THE SKIN. 

The presumption is in favor of all these exanthematous rashes 
being due to a vaso-motor neurosis, either from reflex irritation, 
or direct action on the vaso-motor centers, or perhaps in some 
cases, as Jadassohn thinks, on the peripheral nerve-ends. Beh- 
rend's ingenious view, that those drugs which did not produce 
special eruptions (such as bromin and iodin, which he calls 
dynamic eruptions) produced toxins in the body, has no facts, 
only analogies, to support it, and is unnecessary, as the theory of 
nerve influence is more probable and is sufficient to account for 
them. Brooke supported this view in a well-argued paper, with 
which I agree. On the other hand, I cannot accept Fox's view, 
that the eruptions produced by the external application of drugs 
is of the same nature as those from the inside, except so far as 
they may be classed with all irritants, which in predisposed per- 
sons will excite a widespread dermatitis from a local irritation. 
There are certain drugs about which there must be some reser- 
vation. They are belladonna, iodoform, and mercury, and in 
rare cases morphia and quinine, whether introduced into the 
body by the mouth, mucous membranes, or skin; the result is in 
certain people to produce an erythematous rash. Belladonna 
does so, probably by its direct effect on the vaso-motor nerves, 
while it is unknown how the others act. The more special action 
of iodin and bromin has already been discussed. 



ANIMAL POISONS. 

Besides the directly irritating effects from the bites or stings 
of insects and contact with certain of the lower animals, there 
remain certain animal poisons, which usually gain an entrance 
into the body by inoculation through some abrasion, pricks, or 
other trifling lesion, and are liable to set up inflammation, some- 
times of a phlegmonous character; the severity of the effect 
depending largely upon the special character of the poison and 
the susceptibility of the patient. These poisons may be specific, 
like those of splenic fever or glanders, or non-specific, as in dis- 
section wounds. They are all doubtless of bacterial or micro- 
coccal origin, though they have not all been identified. As the 
skin manifestations are the least important part of the disease in 
many cases, they can only be briefly considered here. 



DISSECTION WOUNDS. 507 



DISSECTION WOUNDS. 

The inoculation of the virus derived from the dead bodies of 
men and animals gives rise to various troubles, local and 
general, or both, and of trifling or grave importance according 
to the period of the decomposition of the body, the cause of 
death, and the state of health of the recipient of the poison. Of 
the nature of the virus we know little; it probably varies in its 
qualities, and is generally, if not always, of bacterial origin. It 
is most virulent in fresh bodies, and in those who have died of 
septic diseases. The poison gains entrance into the body 
through some trifling defect in the skin, such as a chap, prick, or 
abrasion. 

In rare instances acute and rapidly fatal septicemia may arise, 
without local changes at the site of inoculation; while if pyemia 
supervenes, it is always secondary to other lesions. 

The brunt of the local effects falls upon the cellular tissue, the 
lymphatics, or the skin; in the last, the symptoms being almost 
always purely local, while in the first they are often serious, and 
even fatal. When the cellular tissue is chiefly involved, diffuse 
cellulitis sets in, with brawny swelling of the tissues, starting 
and spreading rapidly from the point of inoculation. In some 
instances so severe is the inflammation as to produce spreading 
gangrene; and the general symptoms are serious in proportion 
to the extent and severity of the inflammation. Lymphatic in- 
flammation may attack either the vessels, or the glands, or both, 
with or without marked signs of inflammation at the site of inoc- 
ulation; here again the general symptoms may be slight or 
severe. * 

The skin lesions are ordinarily boils, whitlows, onychia, or 
pustular folliculitis at the back of the hand. These present 
nothing special in their form or treatment. 

There remain two more characteristic lesions — the Post-mor- 
tem Pustule and Wart, or Verruca Necrogenica, which is de- 
scribed under Lupus Verrucosus, from which it differs only in 
its etiology. 

*For more detailed information, see Holmes' "System of Surgery," 
or similar work; or the article on "Post-mortem Wounds," by Marcus 
Beck in Quain's " Dictionary." 



5 o8 DISEASES OF THE SKIN. 

The Post-mortem Pustule starts from some prick or abra- 
sion, which becomes hot, red, and itching by the next day, and 
in another twenty-four hours a pustule is formed, with pain and 
tenderness, relieved when the pustule is pricked; but pus again 
forms under the scab, with repetition of the symptoms, and this 
may happen again and again, each time the lesion becoming 
larger, unless suitable treatment is employed. Occasionally 
there is sympathetic inflammation of the glands and lymphatics, 
and slight constitutional disturbance. 

Treatment. — Open the pustule, drop in a little iodoform, and 
keep it moist with wet boric lint under oiled silk until it has quite 
healed. 

Erythema Serpens. This is a septic, but not a serious ery- 
sipelatoid erythema, first described by Morrant Baker,* who met 
with many cases in the butchers from Smithfield meat-market. 

It follows on a scratch, c. g., from meat bone, or while dressing 
meat or game, and less often after other trivial injuries not so 
obviously open to animal toxins. From a few days to a week 
or two after inoculation a pink inflammatory blush appears of a 
patchy character, with borders fading into the healthy skin; 
others develop and group into an enlarging circle, so that they 
become more separate. They affect the knuckles and both sur- 
faces of the fingers, and although there is very little swelling, 
movement is much impaired and great pain is complained of, 
tingling, burning, or shooting in character, seldom extending 
beyond the finger and hand. Red lines along the lymphatics 
and swollen glands are quite exceptional. The patient looks 
and feels ill out of proportion to the local symptoms, but there 
are no febrile symptoms of importance. 

The disease lasts from two to six weeks, averaging three: it 
never suppurates, and rarely involves the trunk, lymphatics, or 
veins. 'It is readily amenable to hot boric acid fomentations and 
saline aperients. 

Erysipeloid, as described by Rosenbach,f appears to be a 

* Morrant Baker, St. Bart. Hosp. Rep., vol. ix. (1873), p. 198, with 
colored plate. 

f Rosenbach, Verhandlungen der Deutscken Gesellschaft f. Chir. , 
April, 1897. Also W. Anderson and Colcott Fox, Brit. Jour. Derm., 
vol. xi. (1899), p. 121. 



DISSECTION WOUNDS. 509 

closely analogous, if not s identical, affection met with in the 
same class of persons. It is accompanied by pricking and itch- 
ing about the fingers and hands, extends peripherally while 
dying away centrally, without desquamation; but, unlike Baker's 
erythema serpens, it is described as having a sharply defined, 
slightly elevated, dark violaceous, almost livid red zone round 
the site of inoculation. It gets well in one to three weeks with- 
out treatment. Rosenbach found a coccus which he classed as a 
cladothrix, as it produced a closely woven mass of fine threads 
of various lengths on cultivation. By inoculation of pure 
cultures he reproduced the disease in forty-eight hours. 

" Gayle " in man. In the lambing season ewes are liable to 
a very fatal disease called " gayle," which appears to be a sort 
of puerperal fever. Men who skin animals which have died of 
this disease sometimes inoculate their hands. The result is the 
formation of a pimple, which enlarges into a flat, loculated, and 
therefore lobulated vesicle with a slightly depressed center, 
which may be an inch in diameter, and is of a bluish-gray color 
and with a slight areola. The contents are clear or blood- 
stained serum. There is no pain or febrile disturbance, but the 
axillary glands are enlarged and the hand may be swollen. 
Klein has shown that it is due to a special organism which he 
called " staphylococcus haemorrhagicus,"* from its producing 
hemorrhagic edema when cultures were injected into guinea 
pigs and sheep. J. McNaught observed two cases in men who 
had been killing healthy lambs. One of the men had slight 
pyrexia. It is remarkable that the organism should produce 
such serious general symptoms in sheep and guinea pigs and 
only a local affection of a mild kind in man. It shows that it is 
no ordinary septicemia. 

The treatment is to remove the covering of the vesicle and 
disinfect the surface. Colby used corrosive sublimate. Probably 
1 in 2000 would be the best strength. 

* " A Coccus Pathogenic to Man and Animals: Staphylococcus Hsemor- 
rhagicus," E. Klein, Brit. Med. Jour., August 4, 1897, p. 385; and 
McNaught's letter, loc. cit., September 11. 



510 DISEASES OF THE SKIN. 

EQUINIA.* 

Deriv. — Eqiuis, a horse. 

Synonyms. — Glanders, Farcy; Fr. } Morve; Ger., Rotz. 

Definition. — A contagious, specific disease, with general and 
local symptoms, derived from the horse or ass. 

Glanders is fortunately a very rare disease in the human sub- 
ject. The attempt made by some authors to distinguish between 
glanders and farcy is not scientifically sound or practical, and it 
is best to divide it into acute, subacute, and chronic. The acute 
cases terminate within four weeks, and are almost invariably 
fatal; the subacute go on to six weeks or so; the chronic may 
last for months or years, about fifty per cent, recovering. 

Symptoms. — The general symptoms set in from three days to 
three weeks after inoculation, the site of which is not always 
ascertainable. The early symptoms are vague and indefinite, of 
the usual febrile characters, among which prostration, constipa- 
tion, and vague muscular and articular pains, when severe per- 
haps ascribed to acute rheumatism, are the most distinctive. 
Later on the pyrexia gets more marked, with severe rigors, 
profuse sweatings, and diarrhea instead of constipation; the 
patient sinks into the typhoid state; pyemia, with or without 
jaundice, may supervene, and he dies exhausted. 

The local manifestations affect chiefly, and most distinctively, 
the mucous membranes, the skin, and the lymphatics. 

One of the most characteristic symptoms is a nasal discharge, 
catarrhal at first, then purulent, and often sanious, but always 
thick, tenacious, and offensive; the inflammation spreads to the 
respiratory, oral, and ocular mucous membranes, with corre- 
sponding symptoms. This nasal discharge may occur very 
early, and be very profuse, as in acute glanders, or quite late 
and moderate, as in some chronic cases, and is due to ulceration 
of the mucous membrane, which goes down even to the bone, 
and leads to perforation; it is invariably present at some time 
or other in acute and subacute, but in not more than half the 
chronic cases. In an early stage minute gray points may be 

* Illustrated in International Atlas, Plate XX. Farcin chronique tere- 
brans E. Besnier. 



EQUINIA. 511 

found in the respiratory passages. These are granulations which 
break down into ulcers covered with a broken-down yellow de- 
bris like pus, which is full, of bacilli. If the disease has gained 
entrance through a wound or abrasion, the site of inoculation 
becomes painful, tense, red, and inflamed, and a spreading ulcer 
forms, with foul, loose, irregular edges, chancroid aspect, and 
dirty, sanious, and often offensive discharge. There is swelling 
and often inflammation of the neighboring lymphatic vessels and 
giands, and phlegmonous inflammation, with numerous pustules 
and ulcers, may affect the whole limb or region in which the 
disease started. 

The special and characteristic skin lesions begin deep in the 
corium. In from two days to three or four weeks they appear 
on the surface as scattered groups of red spots, which soon 
become shot-sized papules and change to yellow, and may thus 
sometimes be mistaken for pustules; but pustules the size of a 
pea on livid red bases, and rather like variola pustules, are pro- 
duced if the papules become vesicular or bullous. These may 
coalesce into irregular superficial ulceration, with dirty sloughy 
coating, or dry, black, gangrenous patches may form. Infiltra- 
tions also occur in the subcutaneous tissues, and break down 
into large deep sloughs; these skin lesions are not invariably 
present in all acute cases, the patient sometimes dying before 
they come out. Besides the lymphatic vessels and glands in the 
neighborhood of the inoculation, those elsewhere also enlarge 
and inflame. The nodules thus produced are called in the horse, 
where they are very numerous and marked, " farcy buds "; these 
" buds " may either resolve, or more often suppurate in a low 
form, and break down into foul ulcerating cavities, with indu- 
rated and irregular edges and base. 

These various lesions, the erythema, phlegmonous processes, 
pustules, abscesses, and ulcers may affect almost the whole 
surface, and with the joint troubles fill the patient's cup of 
misery to the brim. 

Etiology. — The disease occurs almost exclusively in those who 
have to do with horses, and so only in male adults ; a very few in- 
stances have occurred where it has been conveyed to women 
and children by the husband and father, who was the first victim. 
In Elliotson's classical case, a laundress w r as infected from wash- 
ing the clothes of a coachman who had died of the disease. The 



5 i2 DISEASES OF THE SKIN. 

disease arises, either by direct inoculation of the secretions 
themselves on a wound, or through the mucous membrane or 
entire skin; e. g., where the horse has snorted in the victim's face, 
and so inoculated the eyes, nose, and mouth. 

Pathology. — It is due to a specific micro-organism, the bacillus 
mallei, the size of the tubercle bacillus, culture inoculations in- 
variably reproducing the disease, as was proved by Loeffler and 
Schutz. Bouchard, Charrin, and others have made similar, but 
not such conclusive observations. 

These bacilli, in film preparations, may be in pairs or single, 
rarely in threads. The bacillus may be pointed at one end like a 
note of exclamation without the dot, or both ends may be 
rounded, or it may be like the italic/. It stands irregularly, but 
best with Loeffler's methylene blue (vide Appendix). It pro- 
duces the toxin called mallein, which when injected into glan- 
dered animals produces severe febrile reaction (102 to 104 F.) 
and a local one accompanied by immense swelling at the site of 
injection, while it has little or no effect on a healthy animal. 

Diagnosis. — When there is no history or evidence of inocula- 
tion or contact with glandered animals, this may be difficult until 
the symptoms of skin, lymphatic, and mucous membrane lesions 
are declared. There is no difficulty when these sets of symptoms 
are present. The bacillus may be detected in the yellow detritus 
which generally covers the ulcers of the mouth, and very often, 
but not always, in the nasal discharge. Even where the micro- 
scope has failed, Strauss' inoculation method has succeeded. 
When glanders pus is injected into the peritoneal cavity of a 
male guinea pig swelling of the testicles occurs within twenty- 
four hours, and a culture of the bacilli may be found between 
the tunica albuginea and the other tunics of the testicle. Accord- 
ing to MacFadyean, agglutination of glanders bacilli by the 
blood of a glandered horse occurs in the same way as in Widal's 
reaction in the serum diagnosis of typhoid fever. I am not 
aware that the mallein test has been used in man, but as it may 
be useful as a therapeutic measure also, the experiment would 
be justifiable when the diagnosis could not otherwise be made. 
Buschke considers it applicable as a test for glanders of internal 
organs. 

Prognosis. — This is always serious, and in proportion to the 
acuteness of the symptoms. 



PUSTULA MALIGNA. 5 r 3 

Treatment. — Nothing has been of any avail in acute cases. In 
chronic ones also, the treatment hitherto has been on general 
principles — to keep up the strength of the patient, and to give 
large doses of quinine, but the success of the anti-diphtheritic 
serum treatment suggests that similar treatment may be avail- 
able here also. Stienon of Brussels tried it in an apparently 
hopeless case. Mallein was injected, beginning with one milli- 
gram, and increasing in the course of sixteen days to thirty 
milligrams. There was marked improvement in a month, and 
recovery took place in a few months more. There was no local 
or general reaction during the febrile period, but during the non- 
febrile period of convalescence there was some elevation of tem- 
perature after injection. Buschke has also used it in chronic 
glanders; he began with one milligram and increased it to a 
gram in the course of a week; the patient did not show any 
local or general reaction and recovered. 

PUSTULA MALIGNA. 

Synonyms. — Anthrax, Malignant pustule; Fr., Charbon; 
Ger., Milzbrand. 

Definition. — A gangrenous carbuncular lesion, produced by 
inoculation with virus containing the bacillus anthracis derived 
from animals suffering from splenic fever. 

Splenic fever is a disease of horned cattle, sheep, and horses, 
which may be communicated to man either by inhaling infective 
particles or by direct inoculation. The first mode of infection 
produces internal anthrax, a general and rapidly fatal disease 
without any skin affection ; the second leads to external anthrax 
or malignant pustule, which is at first a local lesion, from which 
the general system is soon infected. This second or local vari- 
ety is the only one which will now be considered. 

Being derived from contact with the hides or secretions of 
diseased animals, the exposed parts, such as the face, neck, and 
hands, are most commonly attacked. At the site of inoculation 
there is at first considerable itching and burning, soon followed 
by the formation of a livid-red papule, on which arises a bulla 
with serous or bloody contents, or a pustule on an inflammatory 
areola. The bulla or pustule ruptures, and the dark red spot 
33 



5*4 



DISEASES OF THE SKIN. 



beneath dries up into a black, gangrenous eschar a quarter of 
an inch or more in diameter, bordered by small vesicles or pust- 
ules on a hard base, the skin round for a considerable distance 
is of a dusky red hue, densely infiltrated, the boundary being 
well defined, and the tissues edematous, or so indurated that it 
even creaks on section, while the glands and lymphatics of the 
affected region share in the inflammation. The gangrene may 
extend sometimes very rapidly and widely, with a speedily fatal 
issue, sometimes more gradually over a small area; when it 
is arrested, supposing the patient to survive, the slough sep- 
arates in a variable time, according to its depth and extent, and 
healing follows by granulation, as in carbuncle. In exceptional 
cases a widespread and malignant edema takes the place of the 
pustule. 

The constitutional symptoms vary according to the extent of 
the gangrene and the surrounding inflammation, and later on, 
according to the secondary complications. By the time the 
black eschar has formed, general infection of the system has 
commenced, and shows itself by rigors, vomiting, swelling of 
the glands, pyrexia (which may reach 104 F. or more), severe 
pain in the head and bones; the patient sinks into a typhoid 
state and dies comatose, perhaps with convulsions, due to 
meningeal hemorrhage, in thirty or forty hours; or, if the con- 
stitutional infection is a little less severe, lung or other com- 
plications arise, and occasion death in four to six days — seldom 
longer. On the other hand, in favorable cases, with suitable 
treatment, the symptoms gradually subside, the sloughs sep- 
arate, and recovery slowly takes place. 

There is thus (1) a period of incubation of from a few hours to 
a few weeks, without prodromata; (2) the development of the 
local primary lesion of papule, vesicle, and pustule, lasting from 
twelve to twenty-four hours; (3) consecutive brawny infiltration 
and edema round it, gangrene in the course of the next twenty- 
four hours, and death in two to eight days, or a protracted 
recovery. 

Etiology. — The disease chiefly affects those who have to do 
with the hides of diseased animals, such as butchers, slaughter- 
ers, tanners, wool-sorters, etc. It is seldom derived directly 
from the live animals, but flies are sometimes the medium of its 
conveyance, while the flesh, if imperfectly cooked, and milk or 



PUSTULA MALIGNA. 5I5 

butter from the diseased animals, have produced it in rare in- 
stances. 

Pathology. — It is definitely proved that the disease is due to 
the presence of the bacillus anthracis, a rod-shaped organism 

3 jji to 10 // long, and I jx to i . 5 /* in diameter. This grows in 
the blood and all the tissues, and, after the first day or two, may 
be found not only in the fluid from the specific pustule, but also 
in the sweat, sputa, urine, and feces. In the skin it is distributed 
in the papillary layer, as has been demonstrated by Charlewood 
Turner,* A. Barker, and others. 

Diagnosis. — The occupation of the patient, the position of the 
lesion, the presence of a gangrenous patch with vesicular border, 
extensive edema, and induration round it, with the severe con- 
stitutional symptoms, leave little doubt of the nature of the 
affection. 

Before the gangrene has declared itself the occupation is 
often the only clew. Inoculation experiments on animals may 
be used for confirmation of the diagnosis, though it would not 
be right to defer treatment for this; a more ready method would 
be to stain some of the fluid from the pustule, after drying it on 
a cover glass, and search for the bacilli. (For the method of 
procedure see Appendix.) 

The lesion somewhat resembles a malignant facial carbuncle, a 
primary chancre of the face, or a poisoned wound, but the rapid 
progress and gangrene distinguish it from these. 

Prognosis. — The mortality of this local form is about 33 per 
cent., but varies in different outbreaks. The extent of the gan- 
grene, rapidity of its formation, and the constitutional symp- 
toms afford the best data for the immediate results ; later on, the 
presence or absence of complications is the chief guide. The 
presence of the bacilli in the blood and secretions is a very bad 
but not absolutely lethal condition. 

Treatment. — The good results from early f excision, cutting 
widely beyond the central lesion, leave no doubt about this being 
the proper course to pursue. It is not necessary to carry the 
incision beyond the induration laterally, but vertically it should 

* Med. Chir. Trans., vol. lxv., 1S82, in Davies-Colley's paper. 

f Davies-Colley's paper, loc. cit. Case by Morrant-Baker in Brit. Med. 
Jour., June 14, 1884, with colored lithograph. Clinical lecture on a case 
of true anthrax, by A. E. Barker, Clin. Jour., June 5, 1895, p. 91. 



5 i6 DISEASES OF THE SKIN, 

go well down into the fat. The thrombosis of the vessels pre- 
vents there being much bleeding. 

The injection of iodin or carbolic acid (5 per cent, solution) 
under the eschar is a good but less radical and more uncertain 
measure; thus Buck of Leicester records a case of recovery 
which was treated in this way, together with the administration 
of large doses of hyposulphite of soda and large quantities of 
meat; the good result was probably due to the carbolic acid at 
the same time. Poteenko cured four cases with 10 per cent, 
injections of carbolic acid. Three or four Pravaz syringefuls 
were injected into the swelling once a day, and part was soaked 
with a 5 per cent, solution in the intervals. 

Arnold injects one-half per cent, solution of perchlorid of mer- 
cury in a 5 per cent, carbolic solution — one or two syringefuls 
twice a day. Slesarevsky cut away the hard part of the slough 
and dusted with pulverized corrosive sublimate. No toxic symp- 
toms occurred in forty-four cases. J. B. Gresswell has had 
marked success in treating splenic fever in cattle with the sul- 
phite of soda, so that the salt deserves further trial; large doses 
of quinine, five or ten grains every four hours, are also strongly 
advocated. An exclusively animal diet is recommended, on the 
ground that the disease is not communicable to the carnivora; 
but this is not true for cats and dogs, which die if they eat the 
uncooked flesh of a diseased animal. 

VACCINATION RASHES.* 

Vaccination is too often falsely accused of a large proportion 
of infantile eruptions; at the same time it cannot be altogether 
acquitted of being the indirect cause of rashes which are not, 

* Literature. — Illustrated in Author's Atlas. Plate XXXIX. shows 
Impetigo Contagiosa and so-called " Vaccine Lichen," really a papular 
erythema; Fig. 2, Plate XLL, shows a more profuse erythema; and 
Fig. 1, Plate XLII., whilst really a case of varicella gangrenosa, illus- 
trates the kind of gangrene sometimes following vaccination. " Vaccinal 
Eruptions," G. Behrend, Amer. Arch. Derm., vol. vii., October, 1881. 
" Vaccinides," by Dauchez, "These de Paris," 1883. "Vaccinal Erup- 
tions "(five cases), Napier, Glasgow Med. Jour., June, 1883, p. 424. Morris, 
" Introduction to Discussion on Vaccination Eruptions," Brit. Med. Jour., 
November 29, 1890. L. Franck, Amer. Jour. Cut. Dis., vol. xiii. (1895), 
p. 142. Acland, " Vaccinia in Man," article in Allbutt's " System of Medi- 
cine." Reprint, Macmillan, 1897. A good resume of the whole subject. 



VACCINATION RASHES. 



5 J 7 



however, special to it, and are usually transitory, and, if the 
enormous number of children vaccinated be considered, ex- 
tremely rare. Moreover, since there is seldom more than one of 
several vaccinated from the same lymph who show any eruption, 
it is obviously the soil rather than the seed that is at fault, and 
that it is not due to " bad matter," as the laity generally imagine; 
and indeed true vaccine eruptions are more common from calf 
than from humanized lymph vaccinations. 

The following classification is modified from the one proposed 
by Morris, as it did not quite cover all the facts: 

Group I. — Eruptions resulting from pure vaccine inoculation. 

A. Secondary local inoculation of vaccine. 

B. Eruptions within the first three days before the vesicles 
form, which include urticaria, erythema multiforme, vesicular 
and bullous eruptions. 

C. Eruptions following the development of the vesicles due to 
the absorption of the virus include : (a) morbilliform, scarlatini- 
form, and diffuse erythema, erythema multiforme, vaccine 
lichen, and purpura; (b) generalized vaccinia, "vaccine gene- 
ralisee " of French authors. 

D. Sequelae of vaccination, eczema, psoriasis, urticaria, etc. 
Group II. — Eruptions due to the vaccine plus some other 

virus. 

A. Introduced at the time of vaccination. 

(a) Producing local disease: impetigo contagiosa (excep- 
tional), or other form of superficial inflammation. 

(b) Producing constitutional disease: syphilis, leprosy, general 
tuberculosis (?). 

B. Introduced after the development of the vesicles nearly 
always after the eighth day: erysipelas, cellulitis, impetigo con- 
tagiosa (common), furunculosis, granulation tumors, gangrene 
(local or disseminate), pyemia. 

It will be observed that the eruptions in Group I. are un- 
avoidable with our present knowledge, and are largely, if not 
entirely, dependent on the idiosyncrasy of the patient. Those in 
Group II., on the contrary, are all avoidable; those in Division 
A. by scrupulous care on the part of the operator, either as 
regards cleanliness of the patient's skin, or of his instruments, to 
avoid the local effects of A. (a), while A. (b) may be avoided by 
care in the selection of the vaccinifer and in the mode of taking 



518 DISEASES OF THE SKIN. 

the vaccine from the vesicle, or, still better, by the use of glycer- 
inated calf lymph. Very much may be done to avoid the diseases 
under B. in this group by the preservation of local antisepticism, 
e. g., by covering the vesicles with alembroth wool or gauze, 
which may be tacked to the sleeve, and by seeing that the sur- 
roundings of the patient are thoroughly hygienic. The last 
point is not, however, in the doctor's hands, as a rule. 

Taking the above eruptions in their order — 

Secondary inoculation * sometimes occurs between the forma- 
tion of the primary vesicles and the eighth day, and in such cases 
the secondary vesicles catch up, so to speak, the primary one, 
and are mature at the same time. This fact was known to Jen- 
ner. Of this kind is Padieu's f case of confluent vaccination 
over an eczematous surface, from which the child's mother and 
nurse were accidentally inoculated on the face. Lacour records 
a similar case, with fatal result. In Sharkey's J case a similar 
widespread auto-inoculation appears to have supervened on vari- 
cella, though it is given as an instance of variola or varicella. In 
a case from Lassar's clinic, § accidental vaccination over an exten- 
sive eczematous surface occurred from the child having been 
bathed in the same water as the vaccinated baby. Trousseau 
found that reinoculation could be performed successfully up to 
the ninth or tenth day. 

Nicolle and Thiercelin have reported cases inoculated on to 
zoster and herpes labialis. Accidental inoculation, chiefly from 
children to parents, occurs not infrequently, and, as might be 
expected, often in odd places, face, genitals, etc., and I have seen 
it grafted on to impetigo contagiosa of the chin in the child from 
its revaccinated mother. 

Accidental inoculation also occurs from cowpox to man in 
milkers, from horsepox || to grooms, and others who have 

*Dr. Shirley Murphy, who had large experience as one of the directors 
of the Government animal vaccine establishment, informs me that this 
secondary inoculation is not at all uncommon. What he considered a 
well-marked case of this was brought to U. C. H. in the summer of 1886, 
with apparently typical vesicles on the buttocks. 

\ Quoted in Amer. Arch. Derm., vol. vii. p. 89. 

X Sharkey, Lancet, vol. ii. (1887), p. 47. 

§ Reported by Peter, Annales de Der7n., vol. v. (1894), p. 535. 

I Hutchinson's smaller Atlas, Plate XCVIII., face. Langton, Clin. Soc. 
Trans., vol. x. (1877), p. 121, illustrated. 



VACCINATION RASHES. 5 i 9 

treated horses suffering from "grease"; one such case came 
under my observation in which the pocks were more raised up 
and vesicular than in cowpox. In other cases there has been 
enough resemblance to vaccinia to suggest the nature of the 
lesion. The variola of sheep-pox has also been transmitted to 
man. In an observation of Bosc and Bourquier * it took the 
form of a variolous eruption localized to the hand and forearms, 
but it subsided in a week. 

Recrudescence of vaccination sometimes occurs. \ It usually 
occurs shortly after the vaccination, but Sir Thomas Watson 
records the case of a girl of fourteen, in whom, in the course of 
an influenza, vesicles developed on the site of her scars from in- 
fantile vaccination, and an elder sister was successfully revacci- 
nated from the fluid from the vesicles. In Washbourn's % case 
scarlet fever woke up the vaccination of two years before. 

Generalized Vaccinia, the " vaccine generalisee " of French 
authors, occurs under exceptional circumstances, chiefly after 
animal vaccination; the vaccine eruption, instead of being con- 
fined to the points of inoculation, is widely spread. Thus Dr. 
Longstaffe § of Wandsworth records the case of his own child, 
in which there were between eighty and ninety secondary vesi- 
cles, seventy of which were on the vaccinated arm. Colcott Fox || 
showed what seemed to be a genuine case of generalized vac- 
cinia in a child nineteen days old. The vaccine lesion ran a nor- 
mal course until the ninth day, when lesions began to appear 
all over the body, and a large number of pustules very like those 

* Trans. Twelfth Internal. Cong., Moscow, 1897. Abs. in Brit. Jour. 
Derm., vol. ix. (1897), p. 459. 

f Dr. J. R. Williams, Brit. Med. Jour., March 15, 1902, p. 696, relates 
some interesting cases. 

% Lancet, March 8, 1902, p. 664. 

%Brit. Med. Jour., 1883, March 10. 

I Derm. Soc., June 8, 1892. Published with another case in the Clin. 
Soc. Trans, vol. xxvi. (1893), p. 108. At p. 114 is a case by Acland and 
Fisher, with colored illustration, where a child three months old, vacci- 
nated with humanized lymph, had a confluent eruption round the points 
of inoculation by the fourteenth day, followed by a secondary eruption 
over the trunk and extremities in scattered pocks, of which there were 
twenty-eight on the forty-third day. The child died, exhausted, on the 
forty-ninth day. Numerous references. 



520 DISEASES OF THE SKIN. 

of vaccinia developed. Both in this his second case, and 
Acland's, and in other cases, a large number of confluent vaccine 
vesicles formed round the site of inoculation before they ap- 
peared in other parts of the body. 

It is still a matter for discussion whether this multiplication of 
vesicles is only a result of secondary inoculation or of a true 
generalization of the eruption, due either to the exceptional 
activity of the virus or an abnormal receptivity of the patient. 
That it is not the virus is shown by the fact that in many of the 
recorded cases the vaccinia of other children vaccinated with the 
same lymph has run a normal course. That very widespread 
vaccinias may occur from accidental or auto-inoculations on a 
pre-existing eruption has already been shown; but there is a 
residue of cases in which the balance of evidence is in favor of a 
generalization from within, as in the following case of Hugeses 
(de Saida),* a child of four months, who was vaccinated with 
seventeen other children from calf lymph. On the fourth day 
there was a general eruption, which developed into typical 
lesions by the seventh day with high fever and general disturb- 
ance, and the child died on the ninth day. In Gaucher's case 
numerous " boutons " came out all over the body on the ninth 
day in many positions; auto-inoculation by scratching was im- 
possible. The child died on the fifteenth day. 

This is also Haslund's \ opinion of some cases published by 
him; and Acland, in the paper already referred to, adduces cases 
showing the possibility of general infection through the digest- 
ive, circulatory, or respiratory system, for vaccinia, as Chau- 
veau had previously shown, was possible in the horse, into the 
trachea, lymphatics, and veins of which he injected vaccine virus. 
Acland also quotes authorities to prove that on the one hand 
" the receptivity of an individual to successive vaccinations in 
series diminishes during the second week and usually becomes 
extinct before the fourth "; and on the other that, " in inoculated 
smallpox, local manifestations may be reproduced by succes- 

* Maladies Cutanees, vol. xii. (1899), p. 224. 

\ " Vaccinia generalisata und deren Pathogenese," by Haslund, Arch.f. 
Derm. u. Syph., vol. xlviii. (1899), pp. 205 and 371, which gives a resume 
of the subject with numerous references to date. Paul also has contrib- 
uted a paper, expressing the same views, in vol. Hi. (1900), p. 3. Abs. 
Annates de Derm., vol. ii. (1901), p. no. 



VACCINATION RASHES. 521 

sive inoculations over considerable periods of time." Austin 
Martin related an instance of generalized vaccinia (four hundred 
typical vesicles) in a nursling from its revaccinated mother, and 
he cites Cazal, who produced it by giving powdered vaccinia 
crust by the mouth in a child of four refractory to vaccination 
by ordinary methods. There were a hundred and eighty typical 
vesicles. 

Some of the instances reported have been from erroneous 
diagnosis, such as impetigo contagiosa or the confluent bromid 
eruptions, or were probably examples of mild ulcerating vac- 
cinia, such as will be described under Vacinia gangrenosa. 

The other general eruptions under C. have very little that is 
special to vaccination, similar lesions being produced by other 
causes. Under the name of roseola vaccina. Hebra describes 
an erythematous eruption, appearing from the third to the 
eighteenth day after vaccination, analogous to that seen some- 
times at the onset of variola. The eruption consists of red 
maculae from a threepenny piece to the palm in size, commencing 
usually upon the arms, spreading sometimes all over, and leav- 
ing no trace behind. It is accompanied occasionally with a 
slight rise of temperature, lasting only a few hours. This form 
of eruption is rare in my experience, and as a rule the papules 
are smaller. Thus in one such case they were flat, from a pin's 
head to the third of an inch, except one palm-sized patch on the 
left breast; and on the legs they were pin's-point-sized and 
acuminate. Behrend also describes this as morbilliform. I 
have, however, seen extensive diffuse erythema on the trunk, 
while on the limbs there were papules and papulo-vesicles. 
Sometimes the erythema becomes purpuric as in Epstein's * 
cases. He met with 14 cases of " Erythema vaccinosum " out 
of 344 cases vaccinated with calf-lymph. It appeared from the 
fifth to the eleventh day. Many of his cases no doubt would 
come under the eruption which I find most common, and of 
which I have notes of over 20 cases, the so-called vaccine lichen, 
which is really an erythema. It may be either papular, papulo- 
vesicular, or pustular, very rarely bullous. It comes out from 
the fourth to the eighteenth day, most frequently on the eighth; 
begins on the arms in half the cases, and on the trunk, neck, or 
face in the rest; then, by successive crops, it may spread over a 
* Abs. Brit. Med. Jour. Supplement, July 16, 1893. 



522 DISEASES OF THE SKIN, 

considerable part or even the whole of the body, pretty evenly 
distributed, and sometimes tending to form circles or segments 
of circles. 

The papules are acuminate, pin's-point-sized, and bright red, 
and these characters may be preserved to the end. They usually 
remain discrete, but sometimes coalesce into patches; but, as a 
rule, a good proportion of the papules are crowned with small 
vesicles and pustules, and have a red areola sometimes half an 
inch in diameter, the vesicles or pustules being generally small. 
In a moderate number of cases the eruption as a whole is vesic- 
ular, or rather papulo-vesicular, but it is rarely entirely pus- 
tular. 

In the vesicular cases sometimes the vesicles enlarge and be- 
come herpetiform, and more rarely bullous, as recorded by 
Behrend and others. Of this an extreme instance was brought 
to me by Dr. Claremont. A girl of fifteen months was vac- 
cinated with glycerinated calf-lymph; on the eleventh day red 
patches appeared on the face, on which minute vesicles crowded 
in groups, developed and coalesced into elongated bullae, and by 
the sixteenth day some were over three inches long on the vac- 
cinated arm. On the lower limbs the single vesicles varied from 
a millet seed to a large pea. At the time I saw the case there 
were still some erythematous patches with minute vesicles on 
them, and also vesicular circles with a clear center on the thighs. 
There were vesicles also on the palms, soles, and palate. The 
vaccination pocks were a little slow in healing, but there was 
no other abnormality. 

In ordinary cases, when the small vesicles dry up, they leave 
the base as a flat, shining papule, like lichen planus. There is 
rarely any constitutional disturbance, and usually only moderate 
itching, though occasionally it is severe. The rash lasts from a 
few days to a week or two, but in some of the vesiculo-pustular 
cases fresh crops keep on appearing, perhaps for months, 
attended with considerable itching, precisely similar to the 
varicella prurigo of Hutchinson. The following case illustrates 
a good many features of these eruptions: 

A week after vaccination a general, red, conically pointed, 
papular eruption appeared, lasted a week, and then became 
vesicular, first on the shoulders and then down the arms and 
legs, feet, palms, soles, and slightly on the trunk; the vesicles 



VACCINATION RASHES. 523 

became pustules from one-sixteenth to one-eighth of an inch in 
size, with a slight red areola; there was much itching, and the 
eruption continued to come out in crops for some time. 

Wheals are not uncommon in connection with the pruritic 
cases, probably due to scratching, but they are not often seen in 
the early periods; occasionally urticaria is present as early as 
the second day, but it is much more common as a sequela. 
Urticaria pigmentosa has also been observed as a sequel. 

Behrend records typical cases of erythema exudativum 
multiforme in the first week of vaccination, and I have seen a 
well-marked case which began on the ninth day. The flat pap- 
ules enlarged up to flat patches the size of a shilling, and cleared 
in the center into rings. Napier met with a case which began as 
rings on the eleventh day. Norman Walker * relates five cases, 
some like erythema iris. In other cases the papules enlarge 
into convex nodules, from a split pea to half a marble, chiefly 
on the back of the hands and wrists, an erythema nodulare t in 
short. 

Erythema exudativum and urticaria have also been noticed in 
revaccination. Gregory J has described hemorrhagic vaccinia. 

Eczema may either start from the vaccinia pustules in the 
same way that it may start from any other form of dermatitis, 
or begin elsewhere soon after vaccination. It appears to excite 
it only in predisposed subjects, being, as it were, only the match 
to the train already laid, and by no means always in these, as 
eczematous children, who are in otherwise good health, may 
often be vaccinated without any aggravation of existing disease, 
and vaccination has indeed sometimes proved curative. In few 
cases can vaccination be held responsible where the vaccinia 
pustule has completely healed before eczema appears. 

Psoriasis may be mentioned among what may be called curi- 
osities. A case was described by Chambard § which was excited 
by vaccination, and two by Rohe, one a man, the other a boy; 

*N. Walker, Brit. Med. Jour., May 18 (1901), p. 1201. 

f E. A. Barton of Kensington sent me notes of three such cases. 

^Quoted in Hutchinson's Archives of Surgery ', vol. i. p. 195. 

%Aniiales de Derm.et de Syftk., vol. vi. (18S5), p. 498 ; Amer. Jour. 
Cut. a?id Ven. Dis., Rohe, vol. i. p. if. Piffard, p. 119, and T. Wood, 
p. 161. 



524. DISEASES OF THE SKIN. 

both had been vaccinated from the calf. Moulinel * collected 
these and other cases, to which may be added cases by Robinson 
and Rioblanc \ (tenth case), and another by Trufn J in a boy 
of eleven years. It has been suggested that it is the traumatism, 
and not the virus, which excited a pre-existing psoriasis. In 
favor of this is the fact that all the cases I can trace have not 
been infants, but children or adults. In Wood's cases, a man of 
twenty-one with inveterate psoriasis was apparently cured by 
vaccination, while his two sisters of eight and eleven years, 
vaccinated from a calf, were attacked by psoriasis soon after 
the vacinia healed, never having shown any sign of it previously. 
Still more inexplicable, Diday describes a case in which sixty 
days after inoculation round each of the cicatrices a coronet of 
hairs sprang up, which were three-eighths of an inch long four 
months later. Keloid § has occasionally developed on the 
site of the vaccination scars. Of this I have seen two cases. It 
is more likely to occur where from any cause there has been a 
delay in the healing of the vaccinia vesicles. 

Dermatitis Herpetiformis apparently due to vaccination, but 
beginning six weeks after it, is recorded by Pusey || of Chi- 
cago, who refers to a few other cases. It lasted four and a half 
years. Pemphigus has also been reported, but the diagnosis 
has not always been indisputable. 

Bowen of Boston records six cases in children between five 
and ten years, in which distinctly grouped vesicular and bullous 
eruptions developed within four weeks of vaccination in one 
case, and in other cases within one or two weeks. Ringed 
erythema preceded the vesicular element in some cases. There 
was eosinophilia (in two cases eighteen to twenty-one per cent.) 
both in the blood and bullae, and the eruption lasted for months 
or years. In the discussion on these cases the diagnosis was 

*" These de Paris," 1884. 

\ Annales de Derm., vol. vi. (1895), p. 880, with references to date. In 
vol. viii. (1897), p. 1 169 is an abstract of a " These " by P. Vignale, but he 
does not appear to have added another case. 

% Truffi's case is published in abstract in the Annales, vol. x. (1899), 
p. 799. He leans to the diagnosis of seborrheic eczema. 

§ Hutchinson, loc cit.. p. 197. Acland, loc. cit., gives references. 

\Amer. Jour. Cut. Dis., vol. xv. (1897), p. 158 ; and Bowen, loc. cit. % 
vol. xix, September, 1901. 



VACCINATION RASHES. 525 

disputed by some, but as dermatitis herpetiformis is probably 
of toxic origin, there is nothing very improbable about it. A 
well-marked case in an adult was related by Galloway at the 
Dermatological Society in April, 1902, when Sequeira showed a 
pemphigus after vaccination. 

Although a very rare occurrence, the possibility of communi- 
cating syphilis by vaccination has been established by Hutch- 
inson, Cory, and others;* and the same still more rare possi- 
bility must be considered for leprosy. Besides Daubler's two 
cases from Robben Island is the case related by Gairdner. The 
use of calf lymph and clean instruments will entirely preclude 
such a possibility in the future. 

I am not aware of any recorded proof of tuberculosis being 
inoculated with vaccinia, but there are several cases of Lupus 
vulgaris appearing on the site of vaccination, which suggests 
that such an accident is possible and even probable. f 

Of the other avoidable eruptions, impetigo contagiosa is 
very rare, as indeed it ought to be, directly resulting from the 
operation; but as a sequel it is very common. The pus of the 
vaccinia pustule becomes inoculable from the deposition of pus 
cocci from the air or from those already in the skin, and the 
inoculable pus is conveyed to other parts of the body by the 
child's fingers, chiefly at the time when the vaccinated arm be- 
comes irritable. Furunculosis occurs from the absorption of 
these cocci and dissemination through the circulation. Ery- 
sipelas, cellulitis, and pyemia occur chiefly when the hygienic 
surroundings are faulty, but I have known one case of erysipelas 
supervene on an uncured impetigo contagiosa several weeks 
after the vaccinal pocks had completely healed, while in another 
the disease was communicated by the mother to her infant, she 
having visited a neighbor suffering from erysipelas while the 
child's vaccination was incubating, and had herself suffered from 
the general symptoms of erysipelas without any external mani- 

* Such cases scarcely ever occur now. At the East London Hospital 
for Children, where the patients were the poorest of the poor, over twenty 
thousand cases passed through my hands, and I never saw a case, nor 
did any of my colleagues there, or I should certainly have heard of it. 
Colcott Fox has had a similar negative experience at a children's 
hospital. 

f Graham Little, Brit. Jour. Derm., vol. xiii. (1901), p. 81, records a 
case and quotes several others. 



526 DISEASES OF THE SKIN. 

festation. The child first showed the disease on the twelfth 
day.* 

In these cases the disease generally presents itself as a cuta- 
neous and subcutaneous infiltration of the skin, with a well- 
defined, raised, thick, reddened border, which travels up a limb 
or on the trunk an inch or more a day, the infiltration sometimes 
rapidly subsiding in the part traveled over, or the whole limb 
remains distended and hard, with much deepened folds like an 
acute elephantiasis. There is very little or no redness except 
at the border, but generally a waxy hue when distended, or 
slight pigmentation in rapidly subsiding cases. There is often 
very marked febrile disturbance, 103 to 104 F., and if the trunk 
is extensively involved death is likely to ensue, but where only 
one limb at a time is attacked, recovery may occur. 

The ulcerative and gangrenous lesions may be local or dis- 
seminated. I remember a case in which the child was unwittingly 
vaccinated during the incubation of scarlatina, which developed 
before the eighth day of vaccination. The whole of the four 
vaccination places coalesced into a slough the size of a crown 
piece. The child recovered. Balzer met with a similar result 
after revaccinating a syphilitic subject. Hutchinson f relates 
similar cases, some fatal. The disseminated form will be de- 
scribed with other forms of gangrene of the skin. 

Another lesion due to pus cocci is the granulomatous develop- 
ment which may supervene on any ulcerative lesion, the so- 
called botryomycosis hominis when it forms a pedunculated 
tumor, but which may only form a convex moist swelling on the 
site of vaccination. E. Gardner J of Warwick records a case, 
and I know a few other instances. 

The treatment of the erythematous vaccinides is very simple, 
as they rarely last more than a week or two. A laxative, with a 
soothing lotion to allay irritation, such as liq. carbonis detergens 
rrtv to 5j of water or calamin lotion, would fulfill all require- 
ments for the dry forms. For moist, a weak boracic or iodo- 

* A remarkable outbreak (forty-three cases) of chancriform vaccinia, 
supposed to be due to pus cocci, is recorded by Leloir, Le Bulletin Me- 
dical (1889), p. 1419. 

\ Loc. cit., vol. i. pp. 97, 193. 

X Granuloma following revaccination. Brit. Med. Jour., May 29, 1897, 
P. 1347. 



SPHACELODERMIA. 527 

form ointment would be preferable. Where there is a high de- 
gree of inflammation attendant on the vaccinated arm, or else- 
where, a lactate of lead lotion often gives great relief. The 
treatment for the other eruptions will be found in their own sec- 
tions. 

SPHACELODERMIA. 

Dcriv. — GqxxneXoS, gangrene. 

Synonym. — Gangrene of the skin. 

Apart from injury, death of a more or less extensive portion 
of the skin may occur as a kind of pathological accident in many 
conditions, chiefly of inflammatory origin. Most of them may 
be classified under one or other of the following heads, but in 
some we are at a loss to know under which category it would 
be correct to place them. All are due to obstruction of the 
circulation in the part, and that chiefly arterial. A hemorrhage 
into or beneath the skin may also lead to death of the part and 
sloughing, as I have often witnessed. 

c Embolism. 

I. Within the vessel ] r VUr ^ t ^ u ^ c .- 

( 1 hrombosis. 

r Acute arteritis. 

a. Bacterial. 

b. Syphilitic arteritis. 
Calcareous degeneration, 

TT ™ . ,, ! e - A r -. senile gangrene, f Spasmodic, e. g., 

II. Changes in the wallj Contraction of the mus . | symmet rical gan- 

cular or other coats. \ grene. 
Trophic defects, e.g., I Chronic,^, g., ergot- 
acute decubitus. [ ism. 
L Purpuric gangrene from blood extravasation. 

III. Pressure on the ves- j Inflammatory effusion round a vessel. 

sels from without { Tumors, etc. 

Some, like noma and dermatitis gangrenosa infantum, are 
bacterial, and probably gangrene occurring in diabetes has a 
similar origin. The destruction is seldom limited to the skin, 
affecting the other tissues more or less deeply. 

A paronychia gangrenosa has been described by G. H. 
Todd,* resulting in the loss of the terminal phalanges. See also 
Morvan's disease. 

* Dub. Hosp. Rep., vol. ii. p. 274. 



5 28 DISEASES OF THE SKIN. 

Only five kinds of gangrene of the skin need special descrip- 
tion here, viz., Symmetrical gangrene, Hysterical gangrene, 
Dermatitis gangrasnosa infantum, Diabetic gangrene, and Pha- 
gedena tropica. 

Symmetrical Gangrene. Synonym. — Raynaud's disease. 

Definition. — A local arterial ischemia, generally followed by 
asphyxia, occurring at the periphery of the circulation, and pro- 
ducing symmetrically distributed gangrene of the skin and other 
tissues in the affected region. 

This disease, the extreme forms of which are rare, was first 
described by Raynaud,* and his observations have been con- 
firmed and extended by Barlow, Southey, and others. 

Symptoms. — It begins usually after exposure to cold, and often 
without any premonitory symptoms, except sleepiness. The 
parts most frequently attacked are the fingers and toes, espe- 
cially the second and third phalanges, though the nose and ears 
are not uncommonly involved. The affected parts become pale 
and hard, followed by swelling, numbness, and sharp darting or 
stabbing pains. The ischemia and consequent discoloration in- 
crease rapidly or slowly until the part becomes quite black, in 
a period varying from a few hours to a few weeks. Black 
bullae sometimes appear at the line of demarcation, which has on 
its border a red band, but as a rule the gangrene is dry. Separa- 
tion of the whole, or part of the tissues of the affected area, 
slowly ensues. 

Monro found that fifty per cent, had local syncope, ninety per 
cent, local asphyxia, and sixty-eight per cent, had necrosis. I 
have several times observed a progressiveness in the severity of 
the attacks in each succeeding winter, or it may be a diminished 
resistance. 

Variations. — Any part of the body, limbs, trunk, or face may 
be attacked in exceptional cases. As a rule only two extremi- 

* " De l'Asphyxie locale et de la Gangrene symetrique des extremites," 
" These de Paris," 1862, and Arch. Gen. de Med., vol. i. pp. 5, i8g (Paris, 
1874). A translation by Sir Thomas Barlow, for the New Sydenham 
Society, with valuable notes, is published in " Selected Monographs," 
1888. "Raynaud's Disease," by T. K.Monro, 1899. Glasgow: J. Macle- 
hose & Sons. Founded on 180 cases observed and collected. Copious 
bibliography. 



SPHACELODERMIA. 



5 2 9 



ties are involved, but sometimes all four. Thus in Southey's 
case,* a girl of two and a half, it began on the calves, after a 
slight feverish attack, and then numerous patches, becoming 
rapidly gangrenous, appeared on the backs of the legs, thighs, 
buttocks, and upper arms, worst where there was pressure, the 
child dying thirty-two hours from the onset. On the other 
hand, the gangrene may be limited to a small area of the pulp 
of the finger tip, and I have seen it so superficial that only the 
papillary layer was affected and the epidermis was hard and 
mummified, but no scar was left. 

The process may, however, stop short of the death of the part, 
which may simply become white, cold, and hard like wax, and 
after remaining so for a few minutes or a few hours, recover, to 
be, however, again attacked after a varying interval, the local 
syncope eventually passing on to a local asphyxia; or there may 
be local asphyxia without antecedent local syncope. This mild 
condition may also be present on one side, while the other side 
becomes gangrenous, as in T. Smith's case,f a girl of three 
years, in whom the left hand was cold and livid, while on the 
right there was lividity, going on to gangrene of the fingers and 
thumb up to the first knuckles, where complete separation oc- 
curred; or the whole of the phenomena may be entirely uni- 
lateral, but this is exceptional. The pulse is small, even filiform, 
but can be felt close up to the gangrenous part. 

Etiology. — The disease affects both sexes; in adults, males 
more than females, probably on account of their being more 
exposed to vicissitudes of temperature; but all ages are liable 
to it, ranging from two and a half to sixty-three, of whom a 
large proportion are children, and in all ages the female sex 
predominates as two to one (Monro). 

Few positive statements as to more direct causation can be 
made, though exposure to cold has been the determining influ- 
ence in a large proportion; hence the disease occurs chiefly in the 
winter. Some cases have occurred after diphtheria, typhoid, 
scarlatina, measles, malaria, and syphilis, one in connection with 
multiple tumors (B. O'Connor), one with pulsating tumors in 
the brain (F. Treves), two with diabetes (Raynaud and C. Fox), 
many with hemoglobinuria (Wilks, Barlow, Southey, etc.). 

* Path. Trans., vol. xxxiv. (1883), p. 286. 
\Clin. Soc. Trans., vol. xiii., p. 196. 

34 



53© DISEASES OF THE SKIN. 

End-joint arthritis, temporary eye symptoms, and mental de- 
rangement have also been observed in a few cases, and Monro's 
statistics show that twelve per cent, have some abnormality of 
the cardio-vascular system, such as Bright's disease, exoph- 
thalmic goiter, or some allied neurosis. Some cases have been 
pronounced hysterics, and the attacks have been associated with 
polyuria. It has often occurred as a complication of general- 
ized sclerodermia with atrophic shrinking and sclerodactylia, 
seven per cent., according to Monro. Other skin eruptions ob- 
served in association with it are eczema, hyperidrosis, purpura, 
and urticaria both ordinary and factitious. 

On the other hand, many have had no such special antece- 
dents, though it is common to find that the sufferers have habit- 
ually cold hands and feet, and while they are seldom liable to 
chilblains, they are to " dead or waxy fingers," or other symp- 
toms of a poor circulation, the force of which is exhausted before 
it reaches the periphery, although the heart is not necessarily a 
weak one. An impressionable nervous system is present in a 
good many of the patients. 

Pathology. — There are evidently arrest of the arterial supply 
of blood and venous stasis, followed by transudation of blood 
constituents into the tissues. There is a presumption in favor 
of spasm of the arterioles, as the immediate antecedent of these 
conditions, though whether due to a central or peripheral nerve 
influence cannot be established; Raynaud thought it was central, 
Pitres and Veillard regard it as a peripheral neuritis, while Buz- 
zard thinks it is central and due to a blood poison. The associa- 
tion with other nervous phenomena in some cases, such as diph- 
theritic paralysis, or hemoglobinuria, is confirmatory of its neu- 
rotic and toxic origin, and there is growing evidence in favor 
of peripheral neuritis for the majority of cases. 

In Ehrmann's and other cases it commenced with pains radi- 
ating in the forearms along the median and ulnar nerves. 
Probably central lesions high up in the cord or in the medulla 
oblongata may produce similar phenomena. 

Diagnosis. — This is usually easy. The occurrence of coldness 
and lividity, followed by gangrene of the extremities, symmet- 
rically distributed, is pathognomonic, and even where actual 
death of the part does not occur the symmetry is very significant, 
though it may be unequal in degree. 



SPHA CELODERMIA . 531 

Prognosis. — Where the area involved is extensive, or the 
patient very young or very old, or broken down in constitution, 
the prognosis is serious; in more limited cases the dead parts 
separate or are removed, and the patient gets well, though he is 
liable to other attacks. 

Treatment. — The constant current, applied with one pole along 
the spine and the other along the extremity to diminish the 
irritability of the vaso-motor centers, was recommended by 
Raynaud, and has been found to give marked relief. Barlow 
obtained better results by immersing the end of the affected 
limb in a large basin of salt water. The negative pole is placed 
in the water, the other is applied to the limb. The current is 
used as strong as the patient can comfortably bear, contact 
being made and broken frequently to produce contractions of 
the limb. Shampooing is also a useful adjunct. When galvan- 
ism is used quite early, the full development of the attack is 
averted. Hot applications should be avoided; cold and friction, 
as in frostbite, being preferable. Nitrite of amyl and nitro- 
glycerin have been tried ineffectually, as far as the cure of the 
affection is concerned, but they give temporary relief and in cold 
weather improve the circulation while the patient is under their 
influence. Hutchinson recommends opium one-quarter grain, 
quinine two grains three times a day. In cases associated with 
intermittent hemoglobinuria, quinine in three- to five-grain 
doses may be given. Voisin uses oxygen footbaths, and Stoker's 
apparatus would be a convenient way of applying it. When 
gangrene has actually occurred, the limb is treated on the ordi- 
nary surgical principles for dry gangrene. 

Symmetrical Gangrene not due to Raynaud's Disease may 

undoubtedly occur. Phisalix placed a microbial culture in a 
collodion capsule in the peritoneal cavity of a guinea pig, and 
symmetrical gangrene of the extremities, nose, and ears was 
produced. Vidal reported a case in which suppurative peritoni- 
tis with great effusion was followed by symmetrical gangrene of 
the lower extremities. Treves had a case following a pulsating 
tumor of the brain. H. Dufour relates a case following double 
pneumonia, and other cases could be cited.* 

* Author's Atlas, Plate XL., shows moist gangrene which affected both 
feet symmetrically, after direct exposure to cold. 



532 DISEASES OF THE SKIN. 

Hysterical Gangrene.* Synonyms. — Neurotic gangrene; 
Spontaneous gangrene; Erythema gangrenosum. 

Definition. — Cases of recurrent gangrene with no obvious 
cause, which the theory of a neurosis is supposed to explain. 

From time to time cases have been put on record under one 
or other of the above synonyms. 

Probably the most remarkable was that of Doutrelepont, 
which may be taken as the type of nearly all the rest. The pa- 
tient, an hysterical girl, set. twenty-one, was under observation 
for five years, until her death from phthisis. A trifling injury 
under the nail was the immediate antecedent. The day after 
the injury small gangrenous spots appeared on the back of the 
left hand, and successive lesions appeared at intervals over the 
whole limb and left side, and two months from the commence- 
ment the right side also, and later the head and face. The inter- 
vals between the attacks varied, sometimes a month or two. 
A rise in temperature and painful pricking preceded each out- 
break, and then whitish-gray lesions on the same level as the 
normal skin appeared, made up of a group of smaller rounded 
lesions, " herpetiform groups," but the lesions were not vesicu- 
lar to the naked eye, but with a lens there were inchoate vesi- 
cles, which, from the rapidity of the process, did not develop. 
The resulting lesions were always superficial, but most of the 
scars became keloidal, except when the wounds were dressed 
with corrosive sublimate. At a later period, however, vesicles 
and bullae did sometimes precede the gangrene, though sloughs 
without vesicles were the rule. About the end of the third year 
the mouth became involved. Attacks became more frequent, 
affecting every region of the body; mental changes with great 

* Literature. — Doutrelepont, " Ueber einen Fall von acuter multipler 
Hautgangran," Archivf. Derm. u. Syp/i., vol. xiii. (1886), p. 179 (colored 
plate), and sequel in volume for 1890, p. 380, and full abs. Ann. de Derm, 
et de Sypk., vol. i. (1890), p. 583. Joseph, "Ueber multiple neurotische 
Hautgangran," Archiv f. Derm. u. Sypk., vol. xxxi. (1895), p. 323. Bayet, 
" Gangrenes disseminees et successives de la peau d'origine hysterique," 
Annates de Derm, et de Sypk., vol. v. (1894), p. 501. Hallopeau et Le 
Damany, "Alterations gangreneuses et necrotiques multiples et unila- 
terales de l'Extremite Cephalique," Annates de Der?n. et de Sypk., vol. v. 
(1S94), pp. 1261 and 1349 ; Ibid., vol. vi. (1895), pp. 213 and 231. Report 
of the discussion at the Vienna Society of Physicians. 



SPHACELODERMIA. 533 

excitement alternating with depression occurred and led to sui- 
cidal attempts, and five years from the onset the patient died 
from phthisis, but towards the end the frequency of the occur- 
rence of gangrenous patches diminished. 

Duhring's * case was particularly interesting. It started from 
a burn in a woman, get. thirty-four, was vesiculo-bullous, began 
on the left hand, and two years after affected the right hand, 
which eventually had to be amputated. Nothing improved it 
until she had the Weir-Mitchell rest-cure, when the gangrene 
stopped and the places healed. It is noteworthy that she would 
be under closer observation than usual during the cure. Not 
long after she died from opium poisoning, for she was a con- 
firmed opium eater, as well as a pronounced hysteric. Spiller 
made an examination and found some endarteritis and changes 
in the nerves of the right arm, but no central nerve changes. 
In an almost precisely similar case in a young lady, a morphia 
eater, it began also with a carbolic acid burn, and I conclusively 
proved it to be self-inflicted. 

Many other cases in hysterical women have been recorded, 
of which those by Bayet, H. Hebra, Schwimmer, and Joseph 
may be especially mentioned, while Joseph, Boyet, Kaposi, and 
Quinquaud have recorded very similar cases, mostly in neurotic 
men, Joseph's case having been an apparent exception. 

In some of them the vesicular commencement was absent, 
but the type case shows that this is not an essential difference. 
In most of them a slight injury preceded the first gangrenous 
lesion, which did not commence on the site of the injury. In 
Joseph's case the antecedent injury was a sulphuric acid burn, 
and the attacks only recurred every six months, at the beginning 
and end of the winter. 

Since all the women were young and hysterical, and the men 
also were generally described as neurotic and hysterical, the 
theory of self-infliction is the most obvious explanation; and 
while the slight traumatism, so frequently an antecedent, 
has been assumed to be the starting point of a neuritis, and so 
to piece out the theory of a neurotic origin, on the other hand, 

* International Atlas of Rare Diseases of the Skin, Plate XLVIII., 
Fig. 5. Brit. Jour. Derm., vol. xiii. (1901), gives Spiller's account of the 
P.M. changes in abstract, but his discussion of the possible causes of gan- 
grene does not throw much light on this particular case. 



534 DISEASES OF THE SKIN. 

as set forth under k ' Feigned Diseases," a slight injury has often 
been the suggestive element for imposture. Further, some 
cases first published as hysterical gangrene have subsequently 
been proved to be artificial. 

Such was Erb's case, which was proved to be due to caustic 
potash, and by varying the duration of its application it was pos- 
sible to produce erythema, wheals, herpetiform vesicles, and 
bullae. Many cases have commenced, and remained left-sided 
for some time, but the right has generally been invaded at a 
later period. While all this would appear to point conclusively 
to an artificial origin, on the other hand there is the fact that 
many of the cases have been for a long time under the care of 
trained observers fully alive to the possibility of imposture, and 
who have tried all the means in their power to eliminate such an 
error. 

The supposition of a physical neurosis does not really explain 
it, for although a severe neuritis will occasionally lead to gan- 
grene of the skin, as in some cases of zoster, in these cases there 
is only a single attack of the gangrenous process, and our pres- 
ent knowledge does not admit of a satisfactory pathological 
explanation for such cases. No treatment has been hitherto of 
any avail to prevent recurrences. My own experience is 
strongly in favor of the theory of self-infliction. 

Zoster Atypicus Gangrasnosus et Hystericus. Kaposi has 
described a vesicular affection which he considers entitled to the 
above designation. In all the cases, of which he had eleven, the 
main features were an eruption of vesicles and papules, chiefly 
in groups, followed by central scabbing, which was often sur- 
rounded by a corona of pus or minute pustules. In some parts 
from coalescence large areas of gangrene were produced, and 
when the sloughs separated the granulating surface cicatrized, 
often with keloid development in the scar. The eruption stage 
lasted from four to eight days, and then retrogression took 
place. The eruption was symmetrical, did not correspond to any 
spinal or cranial nerves, and showed a marked tendency to re- 
currence; in the first case three times, while in the second and 
third cases there were second attacks after a year or two. The 
first three cases were all in hysterical young women, but the 
fourth was a man who was onlv seen once, and had on his left 



SPHACELODERMIA. 535 

forearm scabbing, vesicular groups, and striae like case three. 
In its unilateral and, possibly, nerve distribution it was therefore 
not on all-fours with the first three cases. Kaposi discusses the 
diagnosis and pathology of the affection, and considers artificial 
production of the eruption may be excluded, and that it was dis- 
tinctly different from the so-called spontaneous gangrene de- 
scribed in Doutrelepont's case and in many others; and finally 
refers it to atypical zoster, as the gangrene, bilateral distribu- 
tion, and tendency to recur were all features which are seen 
occasionally in herpes zoster.* While its nosological position is 
doubtful, it appears not to have any real relationship to zoster, 
and to rank only as at most a variety of hysterical gangrene. 

Dermatitis Gangrenosa Infantum.! Synonyms. — Varicella 
gangrenosa (Hutchinson), Pemphigus gangrsenosus (Whitley 
Stokes) ; Rupia escharotica (Fagge) ; Fr., Ecthyma terebrant. 
Germ. Ecthyma gangrenosum. 

Definition. — A gangrenous eruption, following varicella and 
other pustular eruptions of children. 

This rare condition was first discovered by Hutchinson I as a 
complication of varicella and subsequently of vaccinia § also, and 
since then many cases have been observed by Barlow, Lees, 
Haward, Payne, myself,] and others; there can also be little 
doubt, as Hutchinson remarks, that Whitley Stokes' description 
of an epidemic of " pemphigus gangrsenosus " in Ireland in 1809, 
and, as Barlow has pointed out, the " rupia escharotica " speci- 

* Archiv fur Derm, und Syph., vol. xxi. (1889), p. 561, with colored 
plate, and Hand Atlas, Plates CVIII. and CXII. Abs. Brit. Jour. Der?n. 
vol. i. (1889), p. 278. 

f Illustrated, Author's Atlas, Plate XLI., Fig 1, a severe case following 
miliaria; XLII., Fig. 1, a mild case with varicella. St. Louis Atlas, 
Plate XX., Fig 2. 

% "Clinical Lectures on Rare Diseases of the Skin," p. 235, and a full 
account with Plate, in Med. Chir. Trans., vol. lxv. (1882), p. 1. 

§ A case of vaccinia gangrenosa, with recovery, is also recorded by 
Stokes of Dublin, in Dublin Jour, of Med. Science, June, 1880. It began 
forty-eight hours after vaccination. 

|| See paper by the author in Med. Chir. Trans., vol. lxx. (1887), p. 397 : 
" Multiple Gangrene of the Skin in Infants, and its Causes," with nu- 
merous cases. 



536 DISEASES OF THE SKIN. 

mens in Guy's Hospital museum,* refer to the same condition. 
I have, however, ventured to depart from the name bestowed on 
it by Hutchinson, since it is not, as will be presently shown, al- 
ways secondary to varicella and vaccinia. 

The place of onset and mode of development vary according 
to whether the gangrene appears early or late in the course of 
the varicella, or is independent of that disease. 

If it occurs while the varicella lesions are still present, it 
begins on the head or upper part of the body, and instead of the 
scab being thrown off, ulceration occurs beneath it, and often a 
pustular border with a red areola is formed, the whole resem- 
bling a vaccination pustule. The process extends, both in depth 
and peripherally, until a black slough is formed from a quarter 
of an inch to an inch or more in diameter, the smaller ones still 
with a pustular border and areola. After attaining to a certain 
size, varying very much, the process of separation sets in, and 
when completed, a sharp-edged, roundish or oval, conical ulcer 
is formed, deep or shallow in proportion to the diameter of the 
slough, some of the largest being quite three-quarters of an 
inch deep in the center. Extension of the ulcer seldom takes 
place after the separation of the slough has commenced. When 
they are closely aggregated coalescence will probably ensue, 
and then very large ulcers, irregular both in contour and floor, 
are produced. If any fresh crops are formed, or when it de- 
velops after most, if not all, of the varicella lesions have cleared 
off — perhaps a fortnight or more from the onset — or in cases 
following vaccination, or otherwise unconnected with varicella, 
the ulcerative lesions usually commence on the lower half of the 
body, especially the buttocks and thighs. \ Each lesion begins as 
a pin's-head-sized papulo-pustule, which extends to the size of a 
pea or larger, ruptures, and, except on the buttocks or wher- 
ever it is kept moist, dries in the center to a scab, with the 
pustular border and red areola like vaccinia, and from this point 
follows the same course as those which started in a varicella 
pustule. In some cases the buttocks and parts in contact with 
the napkin, and sometimes the legs and thighs, are fairly riddled 
with ulcers of all sizes, shapes, and depths. On the trunk and 

* Models 206-209. Catalogue, p. 95. 

f D. Heath records such a case limited to the scalp in a child of two 
years. 



SPHA CELODERMIA . 537 

rest of the body they are not usually numerous; and though 
some may be very large and deep, the majority are compara- 
tively superficial. Where the lesions are numerous and deep, 
there is naturally much constitutional disturbance, the tempera- 
ture ranging up to 104 F. or even higher; lung complications, 
tubercular, pyemic, or inflammatory, are very frequent, and de- 
termine or hurry on the fatal issue. Should the child survive, it 
is surprising how rapidly the lesions cicatrize, of course leaving 
deep and indelible scars where the severe lesions have been, but 
some of the superficial ones do not penetrate below the papil- 
lary layer, and these heal with only slight loss of substance, and 
therefore temporary scarring. 

Variations. — In some of the worst cases, where the malignant 
change occurs very early — e. g., in a case of my own on the 
third day, and in W. Haward's * on the fourth — hemorrhage 
takes place into the vesicles, which, from being quite clear, 
become almost black, perhaps the whole of them in the course 
of twenty-four hours undergoing this change. In my case the 
temperature rose to over 105 F., and the child died on the 
twelfth day after the change in the vesicles. Post-mortem 
there were numerous small, softening infarcts in the right lung, 
and broncho-pneumonia in the left. In Haward's case the child 
died on the eleventh day, and in it also there were pyemic ab- 
scesses in the lung. 

On the other hand, there are cases of much milder grades 
than those described, and they are more common than the severe 
form. The ulceration may be quite superficial, the lesions reach- 
ing to the vaccinia-like stage, and then drying up, and there are 
all degrees, from mere excoriations to pretty deep ulceration, 
with or without a few lesions going on to gangrenous 
sloughs. 

Hallopeau f describes what he considers to be a separate dis- 
ease under the name of dermatitis vacciniformis infantilis 
(herpes vacciniforme, Fournier). The lesions are vaccinia-like 
in character, but are quite superficial and heal, leaving stains 
but no scars, with mild antiseptics such as boric acid. They 
occur only in young infants, chiefly where the napkin comes, 
especially in the folds, adjacent parts being often similarly 

* Brit. Med. [our., 18S3. 

fSt. Louis Atlas, Plate XX., Fig. 1. 



538 DISEASES OF THE SKIN. 

affected. In my opinion * they are only the mildest degree of 
the disease under consideration. Pringle's f view, that this and 
the ecthyma terebrant of the French are different to the cases 
described in this country is, I believe, mistaken. 

Sometimes the eruption is distinctly bullous, c. g., in a girl of 
two years old it began as a bulla with clear contents half an 
inch across, then became pustular; other bullae appeared, and 
some began to ulcerate, but no sloughs were formed, and there 
was no evidence whatever of varicella. 

In the vaccination cases the ulcerative lesions do not start 
from the vaccinia vesicles, though beginning usually on the 
vaccinated arm. Their development and course are the same as 
the others, and they are of all grades of severity. 

In the mildest varicella cases fresh crops of papules and pus- 
tules keep on appearing, and the process may last for weeks, 
accompanied by a good deal of itching, but very little if any 
ulceration. This is the " varicella prurigo " of Hutchinson. 

In Atkinson's J case the ulcers were chiefly on the extremi- 
ties; the soft parts of one finger were completely destroyed, and 
there was extensive ulceration of the face, mouth, and tongue. 
The child had no constitutional taint, and recovered. 

Etiology. — All the cases hitherto recorded have occurred in 
infants or young children ; an analysis of my own and eleven of 
others in which the age is stated shows that by far the majority 
occur under one year, the figures being fourteen not exceeding 
one year, six not exceeding two years, and three under three 
years of age. S. Mackenzie had a case of a girl, set. four years; 
the youngest was three months old. 

By far the majority occur in girls; fifteen out of twenty-one 
cases where the sex is mentioned, and of my own cases, ten out 
of twelve were females. 

With regard to the diseases antecedent to it, formerly, most 
reporters of cases accepted Mr. Hutchinson's first opinion, 
which he does not now hold, that they were all consequent on 

* This view is confirmed by a case of A. Fournier, \u which he relates 
the case of an infant, set. sixteen months, which began as herpes vaccini- 
forme and went on to fatal gangrene. Annates de Derm., vol. iv. (1893), 

P. 25. 

f Editorial note to Figs. 1 and 2 of Plate XX. 

% Amer. Jour. Med. Sciences, January, 1884, quoted in Brain, January, 

1885. 



SPHACELODERMIA. 



539 



varicella or vaccinia. No doubt varicella is the most frequent 
antecedent, but there are many others, as I proved years ago, 
and it is now accepted that, under certain circumstances, any 
eruption of isolated pustules may be the starting-point of the 
ulcers; it has also supervened on erythema nodosum with or 
without purpura * (Demme and Caillaud). Among predisposing 
causes tuberculosis has been present in so many, as Barlow 
first pointed out, that it must be more than a mere coincidence. 
In one of my fatal cases congenital syphilis was present, in two 
others rickets, while a few were apparently quite healthy. A 
febrile condition is nearly always present, and cases after 
measles, scarlatina, and enteric fever are recorded. Gangre- 
nous ulcers, of probably similar character, occur sometimes as a 
complication of variola in adults as well as in children. 

Single gangrenous patches, often of large size, are also 
met with in infants and young children, both spontaneously 
and as the result of infectious fevers. They start as a vesicle, 
pustule, or bulla. 

My then colleague, R. Parker, had a case of a girl of twelve, 
in whom a hydroa was aggravated by the administration of 
iodid of potassium into hemorrhagic bullae, which then dis- 
charged and gave rise to extensive ulcerative and sloughing 
lesions, very suggestive of the disease under consideration. 
Audry relates a case in a woman, set. forty-seven, in whom a 
bullous iodid eruption went on to ulceration and sloughing 
owing to the patient having continued the drug after the erup- 
tion had come out. 

Pathology. — Nothing is positively known about the pathology, 
except that Ehlers % of Copenhagen has discovered the bacillus 
pyocyaneus in two cases of the so-called " ecthyma terebrant " 
in children. This has been confirmed by F. Hitschmann and 
Kreibich § also in two cases, who speak of obtaining pure cul- 

* Hemorrhage into the skin is always liable, if severe, to lead to slough- 
ing ulcers. 

f A. Bowes reports such a case in a child two weeks old, and refers to 
others. Lancet, August 31, 1901, p. 586. 

^Ehlers, French Translation, Annales de Derm., etc., vol. ii. (1891), 
p. 793- 

§ Hitschmann and Kreibich, Archiv f. Derm., vol. 1. (1899), p. 81. In 
1888 Wickham found the streptococcus pyogenes as the predominant 
microbe in one case. 



54o 



DISEASES OF THE SKIN. 



tures of this bacillus as a means of confirming the clinical diag- 
nosis of the disease. 

CEttinger, however, has found the same bacillus in relation to 
a pemphigus diphtheriticus with a gangrenous aspect, and Neu- 
mann of Berlin found it with internal and cutaneous hemor- 
rhages. Veillon and Halle * believe an anerobic microbe, the 
bacillus ramosus, to the probable organism. Even if one of 
these is not the constant pathogenic agent, it is highly proba- 
ble that the lesions are due to microbic infection supervening 
upon varicella and other pustular eruptions in children, under 
certain constitutional conditions, of which a febrile state, tuber- 
culosis, and probably congenital syphilis, are the chief, but 
evident cachexia is not essential. 

Diagnosis. — This is not difficult; with or without a history of 
varicella, the occurrence of numerous gangrenous ulcers in a 
young child, or even of deep ulcerations, beginning as pustules, 
enlarging, drying into a scab in the center, and then ulcerating, 
form a group of symptoms quite unmistakable. 

Prognosis. — This is serious in proportion to the tender age of 
the infant, the number, extent, and depth of the lesions, the 
amount of constitutional disturbance, the presence of tubercu- 
losis, pyemic, or other visceral symptoms. 

Treatment. — This must be general and local, but the local 
treatment is the more important. Quinine in one- or two-grain 
doses in milk every four hours is often serviceable. In some of 
my cases sulpho-carbolate of soda in five-grain doses every three 
hours has been apparently beneficial, and my colleague Coutts 
had a rather severe case recover under treatment by opium. 
Any complications must be treated as they arise. 

Locally. — I have found the best plan is to inject subcuta- 
neously carbolic acid one in forty, near the sloughing ulcers; if 
the gangrenous patch is large, three or four injections round it, 
three or four minims in each spot, as in the treatment of car- 
buncle, might be necessary. This stops the extension of the 
gangrene and the attendant infiltration of the tissues round, and 
then the lesions can be treated on the ordinary surgical prin- 
ciples. 

Wet boric lint under oiled silk until the sloughs have sep- 
arated, and subsequently, if few in number, iodoform or iodol 
* Annates de Derm., vol. ii (1901), p. 401, with many references. 



SPHA CELODERMIA . 541 

vaselin, and washing with one in five thousand perchlorid of 
mercury, will keep the ulcers septic; freshly made iodid of starch 
paste, painted on, is another convenient application; Pasteur of 
London found a warm solution of chlorinated lime on lint give 
most relief. These measures and the administration of concen- 
trated, or in young infants, partially digested foods, and putting 
the patient in the best hygienic conditions, offer most chance of 
success, which is almost assured if adopted sufficiently early. 

Multiple Gangrene in Adults. I have seen cases in adults: 
one was a woman, who, after suffering from some suppurative 
lesion of the vagina before she came to the hospital, broke out 
with precisely similar lesions to those of infants, in almost all 
parts of the body, the lesions coming in crops. They had 
scarcely healed before a second outbreak occurred with a rise of 
temperature, and this time the face was affected and disfigured 
with rather deep ulcers. This, it was ascertained, was in connec- 
tion with secondary syphilis. She also had xerostomia of long 
duration. 

It has also been observed in connection with the exanthemata. 
One such was a man, in whom the number of lesions w r as small, 
but symmetrically distributed, the condition being produced 
during convalescence from scarlatina; a diphtheritic-like mem- 
brane developed on the soft palate, and was succeeded by bullae 
and gangrene. Hutchinson records a case of multiple ulceration 
after measles, but there was molecular, not massive destruction. 
Osier had a case connected with malaria. Many cases have been 
noted in enteric fever. 

Its occurrence as a complication of smallpox has already been 
alluded to, and Dr. M. Richards, of the City Hospital, Birming- 
ham, wrote me an account of cases observed by him of various 
degrees of severity — some superficial, beginning as a ring of pus 
round a scab; others with punched-out ulcers with or without 
sloughing bases; and others again beginning as flaccid bullae 
with foul contents; and it would appear, therefore, to be a possi- 
ble but uncommon complication of any infectious fever. 

Hallopeau and Le Damany * described a form of gangrene 

* Hallopeau and Le Damany, Anna/es de Derm., vol. v. (1S94), pp. 
1264 and 1349, and vol. vi. (1895), pp. 213 and 292; also Hallopeau and 
Leredde, p. 435. 



54- 



DISEASES OF THE SKIN. 



which commences as red papules in which a yellow slough ap- 
pears when the epidermis is shed. Ulceration occurs beneath it, 
and spreads eccentrically until the separation of the slough, 
when the ulcer heals slowly. These lesions may be scattered or 
in small groups, attack the head chiefly, but have also been seen 
about the chest and arms and even on the buccal and pharyn- 
geal mucous membranes. The condition occurs in various 
degrees of severity. Some are superficial and heal readily; others 
form a deep, dry, black slough; others get deeper with great 
surrounding induration; while in the worst there is a spreading 
indurated erythema which may extend over a large area with a 
huge slough accompanied by suppurating, and even sloughing 
of the neighboring glands. Janowsky and Mourek's case, of a 
man, set. forty-four, was of this kind, and the origin was traced 
to a fly which inoculated the back of his hand, and produced a 
scar-leaving pustule. Then followed pale red flattened papules 
with a red areola round the hair follicles and skin glands, and 
in these successive gangrenous sloughs formed and spread and 
left pigmented cicatrices. 

Cases following infection with animal poisons are recorded 
by several observers. Waelsch's * case was traced to a foul 
morphia syringe: Gangrenous patches and abscesses killed a 
man, set. thirty-eight years, in three weeks; a bacillus which did 
not stain by Gram's method appeared to be the pathogenic 
agent. 

Hartzell f reports the case of a woman, set. forty-six, which 
began with a wound made by a poisoned meat hook four years 
previously, and led to vaccine-like lesions such as have been 
described in children, which went on to gangrenous sloughs, 
and nothing but excision stopped them. He found abundant 
bacilli at the base of the sloughs, which stained only with gentian 
violet after Weigert's method, also staphylococcus aureus in 
large numbers. 

In a case recorded by Rotter % the gangrene developed from 
pustules which formed on the thigh five months after two small 

*Waelsch, Arch. f. Derm. it. Syph., vol. xxxix. (1897), p. 173. Abs. 
in Annates, vol. ix. (1898), p. 387. 

+ Hartzell, Amer. Jour. Med. Science, July, 1898. 

%Dermat. Zeitschr., vol. ii. (1895), p. 314. Abs. in Annales, vol. vii. 
(1896), p. 229. 



SPHACELODERMIA. 



543 



sores on the prepuce and penis; gangrene of the thigh super- 
vened. Other patches formed down the leg to the ankle and up 
to the scrotum and penis. The areas were large and the depth 
down to the fascia, and there were outlying pustules, but all 
healed in about seven months from the outset. Thick short 
bacilli were found, cultivated, and successfully reinoculated, 
which he called " bacillus pustulo-gangraenosus." 

Hilbert * records two cases of spontaneous gangrene of the 
eyelids in female infants under one year old; a small pustule, 
with yellow scab, first formed without apparent cause on the 
upper lid, rapidly enlarged, the part beneath became gangrenous, 
^» and when the slough separated a circular ulcer, nearly an inch 
in diameter, was left, which healed rapidly. Both children were 
healthy and well nourished. 

Diabetic Gangrene. Kaposi f describes a bullo-serpiginous 
form of gangrene which is apt to occur in advanced cases of 
diabetes mellitus. A few patches are formed on the limbs in 
successive outbreaks, beginning with bullae on a slightly raised 
base; the bulla dries up in the center, and is occupied by a black 
crust, whilst at the periphery there is a ring of fluid pushing up 
the epidermis. The crust extends, and at the end of some days 
is detached, exposing the sphacelated skin, which, somewhat 
later, separates and leaves a red granulating surface. The re- 
semblance of these lesions to the preceding forms is noteworthy. 
In addition to the multiple, there is a single variety in which por- 
tions of the extremities may slough completely off. Bartholow 
describes a case where there was gangrene of the little finger, 
but no mention is made of bullae. Boyd met with a case of gan- 
grene of the great toe, and cases of gangrene of the penis are 
reported by Fournier and others. 

It is probable that J the diabetic subject offers a favorable soil 
for bacilli or cocci, which lead to the gangrene, just as it does for 
the staphylococci, which produce boils and carbuncles. 

* Viertelj './. Derm. u. Syp/i., vol xi. (1884), p. 117. 

f Kaposi, Wien. med. Presse, quoted in Ann. de Derm, et de Syph. y 
January 24, 1884, with review of other skin lesions connected with diabetes. 
See also Quehery, " These de Paris," 18S5, abst., loc. cit., 1885, p. 6go. 

X Grossmann, " Ueber Gangran bei Diabetes Mellitus." A. Hirschwald, 
1900, p. 134, further elaborates this view. 



544 DISEASES OF THE SKIN. 

Phagedena Tropica.* Synonyms. — Tropical phagedenic ulcer; 
Aden ulcers; Malabar ulcers, etc. 

We owe our knowledge of this formidable affection chiefly to 
French writers, especially in Cochin China and Tonkin, where it 
is very rife and malignant. Parke also gave a good account of it, 
as seen in the Emin Pasha Expedition. It is met with in tropical 
latitudes all over the world — Asia, Africa, the West Indies, and 
Central America — and, to some extent, in more temperate 
climates, such as Algiers and Egypt, while it is especially rife and 
malignant in Cochin China, Tonkin, and the islands and shores 
of the Red Sea. It attacks chiefly those who 'are under depress- 
ing influences, such as are due to malaria, privation, overfatigue, 
etc. Then the smallest lesion which produces a breach of con- 
tinuity of the skin gives entrance to the pathogenic microbe, 
and a vesicle or bulla soon forms, and from this the destructive 
process radiates both laterally and vertically. 

The disease occurs in a mild and chronic or in an acute and 
severe form. 

A traumatic or inflammatory lesion, often trivial, is the start- 
ing point, from which either form proceeds directly or from a 
supervening abscess, bulla, or vesicle. 

The mild form. — Boinet of Tonkin distinguishes three stages : 

i. Onset and establishment of the phagedena. 2. Atonic 
ulceration. 3. Repair. 

The affected part becomes red, painful, and swollen, and exco- 
riated from scratching, and there is a serous or sanious dis- 
charge. The edges of the sore become swollen and indurated, 
and are surrounded by a dusky red areola. Spreading laterally 
and vertically, the borders and surface are eaten away by molec- 
ular disintegration, forming an ulcer with irregular floor cov- 
ered with a grayish slough bathed in yellowish or sanious pus. 
When the slough is separated the inflammation becomes less 
active, the ulcer gets paler and may remain stationary, and 
gradually becomes painless, but there is still a putrid pultaceous 
covering on the floor. 

* Literature. — Hirsch, "Phagedenic Tropical Ulcers," vol. iii. p. 690 
Syd. Soc. Edit., with bibliography. " De l'ulcere phagedenique observe 
au Tonkin," E. Boinet, with references, Ann. de Derm, et de Syph., vol. i. 
(1890), p. 210. one of the best accounts, founded on 615 cases, from which 
this article is largely derived. "The Ulcer of the Emin Pasha Relief 
Expedition," T. H. Parke, Lancet, December 5, 1891. 



SPHACELODERMIA. 



545 



The general condition of the patient and the position of the 
ulcer determine the time of onset of the second stage, when 
there is vertical and lateral extension of the sore, with punched- 
out borders, which subsequently become indurated and everted, 
and fungating granulations spring up through the foul gray 
covering. There is a constant and copious serous discharge, 
but enlarged glands are rare except in broken-down constitu- 
tions. The third period of cicatrization may not begin for 
several months. 

The atonic ulcer and the skin for some distance round it are 
almost devoid of sensibility, and Moisson says that if ampu- 
tation is necessary the incisions must be made well above the 
anesthetic area, or the gangrene will probably recur in the 
stump. 

The severe form is always grafted on a previous wound. The 
invasion is rapid, acute extensions of the gangrene recur re- 
peatedly, and there may be dangerous complications. Gastric 
and slight febrile disturbances mark the period of invasion, the 
wound swells with or without a small subcutaneous abscess, 
vesicle, or bulla, which bursts and discharges a sero-sanguino- 
lent fluid. 

In the worst cases, to quote from Parke, " rapid phagedenic 
ulceration spreads from the seat of origin of the disease; the 
soft parts all yield in succession, but some much more slowly 
than others. An ashen-gray slough covers the affected surface ; 
the skin and subcutaneous tissue rapidly disappear and expose 
the sheaths of the muscles; the muscular tissue itself decomposes 
more slowly; the nerves and arteries are destroyed only after a 
prolonged resistance; the tendons soon lose their muscular at- 
tachments, and hang about in shreds," and eventually even the 
bones are attacked, and the superficial layers exfoliate. 

This havoc is wrought not by a continuous process, but by 
the frequent recurrence of acute gangrene, and the fetid sloughs 
are mixed with gelatiniform exudation and copious yellow 
serum. 

The gangrene may spread into the infiltrated red edematous 
tissue round the ulcer, and convert it into soft, filamentous, 
dirty gray sloughs, like those of caustic potash. Death may 
ensue from the extensive ulceration, the deep burrows and irreg- 
ular sinuses, or by the opening of some of the larger joints and 
35 



546 



DISEASES OF THE SKIN. 



their subsequent suppuration. Repeated exacerbations mark 
the unfavorable course, while in favorable cases the discharge 
diminishes, the slough separates, and healthy granulation takes 
place. Even then, however, fresh gangrene may occur, or the 
ulcer may become atonic and callous, with indurated bluish-gray 
edges. 

Cicatrization proceeds from the center to the periphery, but 
the sore may take from one to two years to heal soundly ; for the 
cicatrix, while still thin, breaks down with slight friction or 
stretching, and if the fissures become reinoculated the whole 
process starts again. 

The duration varies according to the age of the patient, the 
seat, extent, and depth of the ulcer, and the gravity of the com- 
plications, which are usually the cause of a fatal result. 

The liability to slight injuries of the lower extremities, espe- 
cially in bare-footed natives, explains why the ulcers generally 
begin on the feet, the ankle, or leg, but the thigh is occasionally 
attacked, and even the upper extremity has been affected, so that 
doubtless no part is exempt. 

Etiology. — Although most common among the colored races 
who inhabit these hot countries, white people are also attacked, 
but less severely, unless pulled down by the cachexia induced 
by malaria, which offers a favorable soil, or by scurvy, famine, 
and physical exhaustion, which are also favoring factors. It 
is always worse in damp, malarial, low-lying districts, but it 
also occurs in non-malarial regions, such as New Caledonia and 
the highlands of Abyssinia. 

The disease is propagated chiefly if not entirely by inoculation, 
and Boinet says the mild form is less inoculable than the severe 
form, because the serum, while it contains more cocci, has fewer 
bacilli, especially of the elongated form, which are the most 
virulent. 

Pathology. — Boinet has found what he belies es to be the 
pathogenic bacilli. They are aerobic, more abundant in the 
sloughs than in the serum, most numerous in the severe forms, 
sparse in the clean ulcers in the healing stage. The degree of 
contagion appears to be in proportion to the number of the 
bacilli. They also infiltrate the tissue round the ulcer, and can 
be found in the blood there. They are long, immovable, often 
straight, sometimes sinuous or undulated, are always extra- 



SPHA CELODERMIA . 5 4 7 

cellular, and have a special predilection for dissociating the 
connective tissue fibers. He also found some smaller rods of 
equal thickness, but very short, with abrupt slightly rounded 
ends, probably derived by segmentation from the long ones. 
He has cultivated these organisms and successfully inoculated 
animals, and has furnished clinical proofs that the pus is inocu- 
lable. He thinks the water of the rice fields contains the 
microbe, but it cannot be the exclusive source. Blaise * has 
found, associated with common bacteria, some straight or 
curved organisms, some distinctly spiral, but he could not get 
pure cultures. Le Dantec f agrees with Vincent and Coyon's 
observations, and says it is the same as hospital gangrene. In 
this Matzenauer finds an anaerobic bacillus. 

Treatment. — Improved hygienic conditions are most impor- 
tant; rest, good food, quinine, and other suitable tonics are 
clearly indicated. Locally, for the severe forms, scraping, the 
actual cautery, and various caustics are recommended by French 
writers, but Parke found that pure carbolic acid succeeded 
rapidly and perfectly, " leaving, when the slough separated, a 
healthy granulating surface." In milder forms the indication 
always is to render the sore aseptic as soon as possible. Parke 
found permanganate of potash most useful, and when he was 
hard up for that, gunpowder acted efficiently. These remedies 
suggest iodoform and its congeners as most likely agents. 
Salicylic acid, boric acid, and pyrogallic acid also have advo- 
cates. Probably, in nearly all cases, the application of strong 
carbolic acid, and subsequently iodoform or sublimate dressings, 
would fulfill all requirements. Le Dantec advocates, when the 
ulcer is clean, firm support to the ulcers with diachylon strips. 

* " L'ulcere phagedenique des pays chauds en Algerie," H. Blaise, 
Gazette hebdom. de Med. et de C/tzr., October 10, 1897, p. 961. The 
patients were porters in the Madagascar Expedition. 

f Abs. Brit. Jour. Derm., vol. xi. (1899), p. 259. 



CLASS III. 
HEMORRHAGIC— HEMORRHAGES. 

PURPURA. 

Deriv. — nopcpvpa, purple. 

Synonyms.— Haemorrhcea petechialis; Fr., Purpura; Gef., Pur- 
pura; Blutrleckenkrankheit. 

Definition. — Hemorrhage into the cutis due to disease. 

Purpura must be regarded as a symptom rather than a dis- 
ease, the outcome of many pathological conditions, some of 
which are obvious enough, while others are so obscure as to 
baffle investigation for the present. Some authors have 
restricted the use of the term to those apparently spontaneous 
cases in which the hemorrhages may be the only obvious symp- 
toms, and call those hemorrhages of which the cause is known, 
symptomatic; but as our knowledge advances, the unknown 
group becomes smaller, and it is therefore more logical to con- 
sider purpura as a term synonymous with non-traumatic hemor- 
rhage into the skin or mucous membranes. 

It is, however, necessary, for the sake of making the descrip- 
tion clearer, to treat these so-called idiopathic hemorrhages as 
definite varieties, which are divided into P. simplex, P. hsemor- 
rhagica, P. rheumatica, and Hematidrosis. 

Blood may be extravasated into the tissues, (i) between the 
layers of the epidermis, (2) into the papillae and corium, (3) and, 
more rarely, into the sweat glands, hair follicles, and subcuta- 
neous tissues. 

The clinical aspect varies according to the position and ex- 
tent of the extravasation, and the following terms are employed 
to describe the appearances thus produced: 

Petechiae, or spots beneath the epidermis, round, oval, or 
irregular, from the size of a fleabite mark up to half an inch or 

548 



PURPURA. 549 

more. They are not raised above the level of the skin, are of 
some shade of purple, and do not alter on pressure by the finger. 

Vibices, or streaks, are long in comparison to their width, 
from about an eighth to one inch in diameter. 

Ecchymoses, or bruises, are of any size and shape, and usually 
accompanied by swelling. 

Ecchymomata, Hematomata, or blood tumors, due to the 
rupture of a comparatively large vessel, may be superficial or 
deep, and vary in extent, shape, and elevation above the surface. 

Papules are formed when the diffusion is round a hair follicle, 
either independently or as a complication of other eruptions, 
and the names P. papulosa or lichen lividus have been some- 
times employed to designate such cases. They also occur in the 
hemorrhagic forms of erythema, and when first formed often 
are of bright red tint as if ordinary inflammatory convex pa- 
pules, but they do not pale on pressure. 

Hemorrhagic Bullae are formed when the effusion is between 
the layers of the epidermis, or hemorrhage may take place into 
a previously formed bulla. 

Hematidrosis, or bloody sweat, occurs when the blood has 
escaped into the sweat follicles or ducts. 

Differences are produced also when the hemorrhage occurs 
as a complication of other eruptions, as in herpes, pemphigus, 
acute circumscribed edema and other forms of urticaria, ery- 
thema exudativum, especially erythema nodosum, and ecthyma. 

Petechiae are much the most frequent of these lesions. When 
first formed they vary in color from a bright red to claret or 
deep purple, and as absorption takes place they change into the 
bluish, greenish-yellow, and brown tints of an ordinary bruise. 
They come anywhere, are never transitory, do not at any period 
disappear or alter by pressure, never increase in size except by a 
fresh hemorrhage, and are visible after death. 

Purpura Simplex. This may be taken as a type of the affec- 
tions to which the title of purpura is often restricted. In it 
apparently spontaneous hemorrhages make their appearance 



55© DISEASES OF THE SKIN. 

suddenly, often in the night, and generally without previous 
symptoms. In adults the hemorrhages most frequently come 
first upon the lower extremities, especially the flexor aspect of 
the thighs and calves, but almost any part may be attacked, and 
in children I have seen them generally appear first upon the 
neck and upper part of the back, and even in the mouth. The 
lesions are petechial, of any size, usually roundish or oval, but 
may be irregular, and in rare instances, circinate (Duhring, Stel- 
wagon). They come in crops, are usually symmetrical, but occa- 
sionally unilateral, and give rise to no inconvenience — indeed, 
the patient would be unconscious of them if he did not see them. 
The spots last until the usual changes, which occur during 
absorption, have been gone through, but fresh crops of petechias 
continue to appear, for a period varying from a few days to a 
few weeks. In exceptional cases the outbreak of purpura is 
preceded by lassitude, aching in the limbs, especially the calves, 
anorexia, and general malaise; but these symptoms are more 
common, though not invariably present, in the more severe 
forms of purpura. One of my cases, a woman set. twenty-nine, 
had suffered from repeated attacks for twelve years on the lower 
limbs, chiefly below the knee, so that the legs were of a deep 
sepia tint all over. She was subject to anemia, but if she took 
tonics had epistaxis. 

Purpura Senilis. Bateman * first described this form, which 
occurs only in the forearms in very old women. " It appears 
principally along the outside of the forearm in successive dark 
purple blotches of an irregular form and various magnitude. A 
constant series of these ecchymoses had appeared in one case 
during ten years, and in others for a considerable period; ana 
in all the skin of the arms was left of a brown color." Unna 
has revived interest in this trivial condition, and from micro- 
scopic investigation concludes that it is primarily from diapede- 
sis, but slight traumatism, c. g., scratching, may lead to more 
extensive hemorrhage by rupturing the vessel. 

Purpura Hemorrhagica (land scurvy, or morbus maculosus 
Werlhoffii) may be regarded as an exaggerated P. simplex, and 

* Bateman's Atlas, 1828, Plate XXX., and Unna, on " Purpura Senile," 
Maladies Cutanees, vol. v. (1896), p. 129 (Translation). 



PURPURA. 55 1 

is often preceded, in addition to the above symptoms, by head- 
ache, great debility, joint pains, which are sometimes severe, and 
convulsions. On the other hand, there may be no symptoms at 
all before the hemorrhages, or P. simplex may develop into this 
form. The lesions present every variety of aspect; beginning 
upon the legs and lower part of the trunk, they rapidly involve, 
bv successive crops, the whole of the body surface. Sooner or 
later the hemorrhages occur internally, especially from mucous 
membranes and into the parenchyma of organs and various 
cavities, and epistaxis, hemoptysis, hematemesis, or hematuria 
may ensue, so profusely as to rapidly undermine the strength of 
the patient, and lead to speedy death by exhaustion. The fatal 
event may also be produced by the position of the hemorrhage, 
e. g., in the meninges, or brain substance. On the other hand, 
the bleeding may be more moderate and continue for a few 
weeks, or may cease altogether in about a fortnight, either 
abruptly or gradually, the general health being affected in pro- 
portion to the amount of the hemorrhage. 

There are also cases of purpura with elevation of temperature, 
or P. febrilis, but probably they are not all of the same nature, 
as in some the fever precedes, and in others follows, the pur- 
pura; in the latter case, possibly due to the absorption process, 
and where the fever occurs in the latter stage of P. hemor- 
rhagica, Immerman suggests that it may be due to the anemia. 
Some authors limit " WerlhofFs disease " to cases in which there 
are violent hemorrhages without any other symptoms or trace- 
able cause, but this is an artificial division. 

Peliosis, or Purpura Rheumatica, is described with the exu- 
dative erythemata, with which it agrees in all its characters, ex- 
cept the hemorrhages, which have in rare instances developed 
into P. hemorrhagica. See also Erythema Hcemorrhagicum. 

Hematidrosis is described with diseases of the sweat glands. 

Etiology. — Purpura occurs in both sexes and at all ages. The 
causes of cutaneous hemorrhages are very numerous, and may 
be classified under five heads: 

i. Certain blood alterations. — (a) Specific fevers, especially 
typhus, variola, hemorrhagica, and epidemic cerebro-spinal 
meningitis; less often, typhoid, measles, scarlatina, acute septi- 



55 2 DISEASES OF THE SKIN. 

cemia, pyemia, and syphilis, both congenital and acquired, some 
forms of pneumonia, probably from pneumococci; Sansom 
records a case which followed influenza; (b) snake-poison; (c) 
some drugs, as iodin, iodid of potassium, quinine, salicylic acid, 
copaiba, belladonna, ergot of rye, chloral, chloroform inhala- 
tion in the early stage, benzoic acid inhalation, phosphorus, 
mercury, and the mineral acids. Purpura is produced by drugs 
such as the above only where there is an idiosyncrasy in the 
individual ; various toxins may produce it, antidiphtheritic serum 
injection, general gonorrheal infection, etc., (d) certain general 
diseases and cachexias, as scurvy, hemophilia, leukocythemia, 
pernicious and other anemias, rickets (scurvy-rickets); cancer, 
sarcoma, and tuberculosis; the last is rather rare, but purpura 
may precede, occur in the course of, or towards the termination 
of phthisis or of general tuberculosis.* 

2. Many diseases of the viscera, including some ot those of 
the spleen, liver (especially cirrhosis f and chronic jaundice 
from any cause), intestines, kidney, and especially from chronic 
Bright's disease, but also from acute nephritis; the lungs, espe- 
cially pneumonia, and the cardio-vascular system, acting prob- 
ably and mainly through the sympathetic. Some of these 
visceral changes may act by allowing micro-organisms or their 
toxins to enter the blood stream. 

3. Want of support to the vessels, due to (a) relaxation of the 
tissues, as in old age, getting up after long illnesses, parturition, 
etc.; (b) the existence of other eruptions, especially bullae, wheals, 
etc.; (e) diminished atmospheric pressure. 

4. Sudden changes in the circulation, as in purpura of the new- 
born (P. neonatorum). Herbert Spencer J has shown that vis- 
ceral hemorrhages, especially into the supra-renal capsules, are 
very frequent in stillborn infants, but they are chiefly due to 
external mechanical causes, and are not true purpura. 

5. Diseases of the nervous system. — (a) Functional, as in con- 
nection with shock, grief, epilepsy, angina pectoris, and other 
neuralgias: (b) organic, as in tubercular meningitis, plugging of 

*Abs. of a paper by E. Cohn in Brit. Jour. Derin., vol. xiv. (1902), p. 
79. gives several quotations and references. 

f In an alcoholic cirrhotic patient of mine hemorrhage into the skin of 
the face and hemorrhagic bullae on the soles preceded death by a few 
days. 

%" Trans. Obst. Soc," vol. xxxiii., 1891. 



PURPURA. 553 

cerebral sinuses and some other serious lesions, also in posterior 
myelitis, injuries to nerves, etc. 

Among all this long list of causes, in only a few, viz., the first 
three specific fevers, and scurvy, hemophilia, and snake-poison- 
ing, can cutaneous extravasations be considered a common 
event. And as they are only a part of many other hemorrhages 
and lesions, they are not usually spoken of as purpura. In most 
of the others it is quite exceptional, while in a great number, per- 
haps the majority, of cases of purpura, the cause is more or less 
obscure. 

Pathology. — The evidence grows rapidly as to the importance 
of toxins, whether of bacterial or other origin, in the production 
of probably all the severe forms of purpura and of many of the 
milder forms. 

Oddo and Olmer after extensive investigations conclude: 
That while purpura may occur without recognizable visceral 
lesions, they are frequently present, before, during, or after the 
purpura. 

The antecedent diseases are either (a) those which determine 
the mode of entry of infective material, generally bacterial, into 
the circulation, such as bronchitis, pneumonia, enteritis, or ton- 
sillitis; or (b) those which produce the purpura by auto-intoxica- 
tion or alteration of nutrition, such as diseases of the liver and 
kidneys, especially cirrhosis and nephritis. Cardiac disease, an- 
other factor, they think, acts through the liver and kidneys. The 
kidneys and liver (as in acute yellow atrophy) and gastrointes- 
tinal canal may also produce toxic infection, which predisposes 
to what they call the cachectic purpuras. Some cardiac, pul- 
monary, and splenic diseases, and meningitis and myelitis also, 
play a part in this form. The only visceral sequel of purpura 
besides those due to hemorrhages into them is Hanot's * hyper- 
trophic cirrhosis of the liver with intense pigmentation.! 

The evidence on which the bacterial origin of many cases of 
purpura rests is (i) on its occurrence along with recognized 
bacterial diseases, (2) on its occurrence in groups, and in a few 
cases (3) the actual discovery of organisms in the blood. Thus it 

* Archiv Gen. de Med., February and March, 1900. Abs. Brit. Med. 
Jour., May 12, 1900. 

f A good example by Apert, Bulletin Medicate, July 10, 1898, p. 665. 
Also in " Thesis," 1897, Apert discusses pathogeny and varieties of purpura 



554 



DISEASES OF THE SKIN. 



is known to occur with acute specific diseases. Groups of cases 
have occurred among soldiers in barracks and in schools. 

Bacteria or micrococci have been found blocking vessels be- 
neath purpuric patches by Cohnheim, Cornil, Watson Cheyne, 
Letzerich,* Cassel, Wilson, etc. Pneumococci have been found 
by Glaisse, Ch. Levi, etc. Streptococci were found in the blood 
of a case under Cureton,f of the Salop Infirmary. Michel- 
Dansac found the bacillus coli in the spleen and blood in a case 
which supervened on leukocythemia. The anthrax bacillus, the 
bacillus pyocyaneus, and the staphylococcus aureus and albus 
have been found by different observers. That the intervention of 
bacteria is not always necessary is shown by its occurrence 
after diphtheria anti-toxin and by Weir Mitchell's experiments 
with snake-poison, in which contact of the poison with the ves- 
sels produced weakening of the vessel walls, and rupture in a few 
minutes, which was general in distribution, when the poison was 
absorbed. Another illustration of the rapidity with which animal 
poisons produce purpura is a case by Mason,J in which a man 
was taken with hemoptysis six hours after an abrasion by a 
sheep's foot, and in twenty-two hours there was hemorrhage 
everywhere. Bacilli were found. 

Graham Little § has collected eleven cases in which severe 
purpura was associated with hemorrhage into the supra-renal 
capsules, and was enabled to demonstrate streptococcus pyog- 
enes in the blood-vessels in two of his own cases. He explains 
this by deducing, from the supposed physiological action of the 
suprarenal capsules, that the first result of the arrest of supra- 
renal secretion would be dilatation of the blood-vessels and 
diapedesis, especially where the surrounding tissues were lax. 
Rapidly fatal cases of hemorrhage into the suprarenal capsules 
without purpura are also on record. Of the different micro- 
organisms found in the blood in a considerable number of cases, 
streptococcus pyogenes was the most frequent. 

* ALtiol. u. die Kenntniss. der Purp. Hem., with plate (Vogel, Leipzig, 
1889). He claims to have found a specific bacillus, and thinks the liver 
is the chief organ of dissemination. 

f Lancet, February 25, 1899, P- 5*5- 

% Australasian Med. Gaz., May 20, 1898, p. 203. 

§ Purpura with hemorrhage into the suprarenal capsules. Brit. Jour. 
Derm., vol. xiii. (1901), p. 445, gives good review of micro-organisms 
found in purpura and many references. 



PURPURA. 555 

The mechanism of purpura * varies greatly. Blood may 
escape from the vessels by rupture, diapedesis, or by transuda- 
tion of blood-coloring matter only, but there is no doubt that, in 
the majority of cases, rupture of the vessel takes place. This 
may occur from: 

(a) Increase of blood pressure behind the point of rupture, 
especially if suddenly produced. The commonest cause of this 
is some obstruction in a vessel, produced by (i) stasis, either 
from inflammation in the part, or from some external pressure; 
(2) thrombosis or embolism, which may be due to an ordinary 
blood clot, masses of leukocytes, as in leukocythemia according 
to Ollivier and Ranvier, sarcoma cells, hematin, fibrin, colonies 
of bacteria or micrococci, or masses of endothelial cells from 
desquamative arteritis, as described by Hayem. The extravasa- 
tions produced by all these blocking particles would thus be 
hemorrhagic infarcts. Extreme contraction of the vessels on 
the one hand, or dilatation on the other, either from active or 
passive congestion, may also lead to rupture of vessels. 

(b) Changes in the vascular walls, from inflammation or 
degeneration, e. g., lardaceous (Wilson Fox), acting either by 
weakening the resistance of the vessel wall or by favoring ob- 
struction; want of support to the vessels being a predisposing 
condition, and the position of the lesions being often determined 
by gravitation. 

(c) Changes in the nervous system acting by producing (a) 
alterations in the caliber of the vessels, and (b) alterations in 
the nutrition of the vessel wall. Schwimmer thinks that pur- 
pura is always a tropho-neurosis, but this is overstating the case. 

The influence of the sympathetic has been shown by the de- 
struction of the sympathetic ganglion in the abdomen of a frog 
being followed by hemorrhages in the lower limbs; and Hale 
White f found acute inflammation of the semi-lunar and cervical 
sympathetic ganglia in a case of purpura hemorrhagica. It is 
probable that toxins act through their influence on the nervous 
system. 

It is only through the influence of the nervous system that we 
can explain such cases as Mitchell's, of neuralgia with extrava- 

*Sack, Monatsh.f. Derm., vol. xx. (1895), and Unna's " Histopathol- 
ogy " may be referred to. 
f Med. Chir. Trans., vol. lxviii. (1885), p 231. 



556 



DISEASES OF THE SKIN. 



sations at the point of greatest pain, the purpura recurring with 
the pain repeatedly; those following injuries to nerves in the 
area of the nerve affected, cases occurring after severe chills, 
those in association with ague, and in the early stage of chlo- 
roform inhalation, even when there has been no struggling 
(Morel-Lavallee). It is, however, generally impossible to deter- 
mine how much is vaso-motor and how much is trophic, or 
whether there is a combination of the two. The same difficulty 
exists also for other pathological conditions producing purpura. 
It is not always possible to say into which category any partic- 
ular case should be placed, either because more than one theory 
would fit the facts, or from there being a combination of causes 
present. Apert * has tried to divide purpuras clinically accord- 
ing to their pathogenesis. Those due to toxins, especially in the 
blood, are peliosis rheumatica or exanthematic purpura; (2) 
microbic emboli, so-called infectious purpuras, with discrete 
petechia? and severe general symptoms; (3) pathogeny un- 
known; Werlhoff's disease with copious hemorrhages and no 
other symptoms. Besides these are secondary cases and mixed 
types. 

Hayem found a diminution of the hematoblasts, which play 
an important part in the clotting of the blood and arrest of 
bleeding; but the pathological changes found in the blood have 
been so diverse, and are individually founded on so few obser- 
vations, and those open to fallacy, that they need not be dis- 
cussed further. 

Diagnosis. — P. simplex has to be distinguished sometimes 
from erythema exudativum and from fleabites. The fact that 
the purpura spot is unaltered by pressure distinguishes it at 
once from ordinary erythema exudativum, which it only resem- 
bles when the purpura is of a brighter color than usual. The 
later stage of flea and bug bites is exactly like the petechia? of 
disease; but the bites do not come suddenly in crops, have a ring 
of congestion round them at the commencement, and a central 
punctum is discernible for the first few days. 

Purpura hsemorrhagica may be confused with scurvy, but ab- 
sence of vegetables in the dietary is never an etiological factor in 
P. hemorrhagica, while the distinctive premonitory symptoms — 
great prostration, frequent faintings, swelling of the gums, 

* Loc. cii. 



PURPURA. 557 

loose teeth, and the condition of brawny swelling of the limbs — 
are always present in a well-marked case of scurvy. The hemor- 
rhages of hemophilia, laikocythcmia, and pernicious anemia are dis- 
tinguishable from P. hemorrhagica by the symptoms of those 
conditions being associated with the hemorrhages. 

Prognosis. — The majority of cases terminate favorably, but 
the duration is very variable, and, as we have nothing to guide 
us as to what course the case will pursue, even an apparently P. 
simplex sometimes passing without assignable cause into P. 
haemorrhagica, it is well to be guarded in prophesying the termi- 
nation. 

Treatment.— -Rest in the horizontal position is one of the most 
important precautions, and should be rigorously insisted upon 
in all cases except the slightest. In P. haemorrhagica every 
effort should be made to support the strength from the first, 
by nourishment in an easily assimilable form, but diet has no 
direct influence upon the hemorrhage. The drugs upon which 
most reliance can be placed are turpentine internally and by 
inhalation, the liquid extract of ergot, and subcutaneous injec- 
tions of ergotin, chlorid of calcium, sulpho-carbonate of soda, 
intravenous injection of perchlorid of mercury: and of these 
turpentine is one of the best; Tt\xv to Tt\xx ter die is the dose. 
Poulet strongly advocates nitrate of silver gr. 1-8 to gr. 1-6, 
made into a pill, and taken three times a day, while perchlorid 
of iron, quinine, and general astringents have their advocates. 

Sansom gave 5ss doses of sulpho-carbolate of soda every four 
hours in two severe cases, and attributes recovery to the drug. 
Wright's experiments with chlorid of lime on increasing the 
coagulability of the blood has led to its employment in purpura, 
and, it is said, with most satisfactory results. Thirty grains 
three times a day is the usual dose, but large doses may be given. 
A full diet, it is said, aids its action. Lusignoli injected perchlo- 
rid of mercury i in iooo intravenously with marked effect. 
Alexeier gave fresh bone marrow of a calf, crushing the bone 
in tepid water. The patient took 5JSS a day of the liquid, which 
was first filtered and then mixed with milk. The hemorrhage 
ceased. Shand of Glasgow records a case in the Lancet of 
July 9, 1879, where faradization of the whole surface seemed 
to have been effectual. Shoemaker recommends 5ss doses of 
the fluid extract of hamamelis virginica. Adrenalin might be 



558 DISEASES OF THE SKIN. 

tried. From what we already know of its pathology it is not 
surprising that all remedies fail in some cases, and it is well to 
have several alternative remedies. Ice, internally and externally, 
is sometimes useful, and local astringents may be employed in 
severe cases; a four per cent, solution of hydrochlorate of co- 
cain, painted on, stopped a severe hemorrhage from the gums 
when other hemostatics had failed. 

Where hemorrhages are due to a general condition like 
scurvy, the treatment for such a condition would be demanded. 

Slight cases require no treatment. 



CLASS IV. 
HYPERTROPHIC— HYPERTROPHIES. 

This group includes all kinds of abnormal increase generally 
produced by the increased number of cell elements of the whole, 
or any part, or combination of parts, of the skin structures. 
There may be real overgrowth or only an accumulation of the 
cell elements, which are the " stasis tumors " of Unna. 

Thus, the epidermis may be affected exclusively, as in cal- 
losities; while in a wart, or other papilloma, the papillae are 
involved as well; or only the pigment of the epidermis may be 
increased, as in chloasma or lentigo; or again, there may be 
increased growth of hair, as in hirsuties; or of nail, as in onycho- 
gryphosis; or of all the tissues, as in elephantiasis. This over- 
growth generally takes place without any signs of inflammatory 
effusion, but in sclerodermia there is effusion of cells round the 
vessels, though, even then, it is not demonstrably inflammatory; 
whilst in elephantiasis inflammation plays the chief part in its 
production. 

Hypertrophy, therefore, is the outcome of many different 
pathological processes, and is a result rather than a cause of 
disease. 

ICHTHYOSIS.* 

Deriv. — ixdva, fish skin, from ixOvS f fish. 

Synonyms. — Xeroderma ichthyoides; Ichthyosis vera; Fish-skin 
disease; Fr., Ichthyose; Ger., Fischschuppenausschlag. 

Definition. — A disease of development with deficient skin 
secretions, characterized by extreme dryness of the skin, and 
more or less formation of scales, epidermal plates, and warty- 
looking growths. 

* Illustrated in Author's Atlas, Plate XLIIL, Ichthyosis Simplex, XLIV. 
Figs, i and 2, and XL V. , Ichthyosis Hystrix, XLVII., Ichthyosis congeni- 
talis, of moderate intensity, the child surviving for some weeks. " Har- 
lequin Fetus " is either still-born or lives a few short hours or days. 

559 



5 6o DISEASES OF THE SKIN. 

Varieties. — Ichthyosis in one or other of its forms is a fairly 
common disease, but varies immensely in its development. 
Three clinical types may be recognized; the first two are general, 
and are called xerodermia and ichthyosis simplex; the third, 
ichthyosis hystrix or hystricismus, is more or less localized. 
All the varieties are usually of congenital origin, though rarely 
recognizable till some weeks or months after birth, and it is not 
until the second year or later that it becomes very conspicuous. 
The term ichthyosis congenita is reserved for the comparatively 
rare cases in which there are defects at birth. 

Acquired ichthyosis in appearance is indistinguishable from 
the others, but it is nearly always secondary and seldom general. 
Xerodermia and ichthyosis simplex are not really distinct, the 
milder being connected by every gradation with the more severe 
form, but their separate consideration is convenient for clinical 
description. 

Symptoms. — Xerodermia is the commonest and mildest form. 
In a marked case the skin is rough, dry, and dirty-looking, with 
the natural lines more marked than usual, from the thickening 
of the epidermis. The roughness is produced by slight furfura- 
ceous scaliness, and also by the prominence of the hair follicles, 
produced by the condition known as keratosis pilaris, which is 
always present, often in a high degree, on the extensor surface 
of the limbs and trunk. Xerodermia may be present in so 
slight a degree that the patient is not aware of it, but such per- 
sons do not perspire, and their skin " chaps " and is more vul- 
nerable to slight irritation. 

In ichthyosis simplex the whole surface has a tesselated 
appearance, fiom being covered with large angular, dirty-white 
finely corrugated, papery scales, which are adherent, and there- 
fore slightly depressed in the center (I. scutellata of Schonlein), 
while the edges are detached, transparent, and shining (I. nacree 
of Alibert, or I. nitida). These and the following variations are 
often most characteristically seen on the leg near the knee and 
ankle, the upper part being often very glistening, or even pearly 
white, while the thick scales are seen lower down. In still higher 
grades the scales adhere together to form thin plates, and being 
of a greenish tint, look something like a serpent's skin (I. ser- 
pentina; when there are still thicker plates, the appearance of 
a crocodile hide is produced (I. sauroderma). The older the 



ICHTHYOSIS. 50i 

plates the darker they become, so that they may vary from 
olive green to black (I. nigricans). While all these fanciful 
names are to be met with in literature, and are therefore ex- 
plained, their use should be avoided, as they only produce con- 
fusion. These extreme conditions are rarely extensive, and 
usually only occupy certain regions, a milder form prevailing 
elsewhere; for, although a universal disease, it is unequal in its 
severity in different regions, and is always more developed on 
the extensor surfaces, especially over the tips of the elbows and 
knees, where it may attain to the higher condition of warty 
growths or plates, even when the disease is moderate else- 
where.* On the other hand, the flexures are comparatively 
free, often appearing quite normal; the limbs are worse than the 
trunk, and the legs than the arms; the palms and soles are not 
much affected, but are harder and smoother from the absence 
of the small natural lines, while the major ones are deepened. f 
The hair is dry, harsh, and dull-looking, and the scalp branny; 
the nails may be pitted and brittle; while the face, though rela- 
tively less affected, is rough and very often eczematous. In 
bad cases there may be a reduction in size of the ocular slit, 
or ectropion, from contraction of the dry skin, and atrophy of 
the lobes of the ears. Unna says there is never ectropion ex- 
cept in I. congenita, and that the face is unaffected. In a case of 
my own the first sign was a roughness on the forehead when 
three weeks old, and it was then shown at the Dermatological 
Society. Six years later it was again shown with well-marked 
xerodermia. Also, in a case of Kaposi's,^ the face was ex- 
tremely affected and the eyelids contracted. 

Itching is frequently experienced, especially when the clothes 
are taken off, but it is never severe unless eczema is present, to 
which the ichthyotic skin is very liable when exposed to cold, 
and also to painful fissures or " chaps " from the same cause. 
The fully developed ichthyotic skin does not perspire sensibly, 
but some sweat may be seen in the flexures, especially the 
axillae, on exertion or in very hot weather, and occasionally on 
the face, palms, and soles. In one of my cases there was con- 

* Plate LI., Fig. 2, Author's Atlas, illustrates this. 

f The rare condition sometimes called Ichthyosis palmae, is described 
under Keratosis Palmse. 

%An?i. de Derm., etc., vol. vi. (1895) p. 686. Report of Vienna Derm. Soc. 
36 



562 DISEASES OF THE SKIN. 

stant hyperidrosis on the palms and soles, with occasionally 
moisture on the back of the hands and forehead, while there was 
a high degree of ichthyosis on the rest of the body. The 
patients feel much relieved by any perspiration, and their condi- 
tion is notably ameliorated in the summer. 

The sebaceous secretion is also deficient, though not wholly 
absent, for the horns and plates have often a greasy feel, and 
ether will dissolve out a good deal of fluid fat and stearin. 
Though the patients are always thin, the general health is good 
as a rule. Asthma is said to be a frequent concomitant, though 
very few instances of such an association have fallen under my 
notice. The ordinary form of the disease tends on the whole to 
get worse, rather than better, as the patient grows up, though 
there may be some remissions, according to the season and to 
the amount of attention given to the skin. After full adult age 
is reached some improvement appears to take place in cases of 
moderate severity. 

Acquired ichthyosis is rare, especially generalized cases. In 
one of my patients it came on when seventy-six years old after a 
period of poor living, became universal, and remained without 
change until his death, six years later; he resembled a typical 
ichthyosis * of the ordinary form. This patient sweated freely 
until the disease came on. Another man, set. thirty-six, with 
marked ichthyosis all over, except the face and upper part of 
the neck, which sweated freely, stated that his skin was quite 
smooth up to the age of thirteen, when it became rough after 
scarlet fever. A third began at sixty-four, and was well marked; 
he suffered from habitual looseness of the bowels, four or five 
motions a day. Tommasoli's case began at the age of seventeen 
years. Mapother's case was a woman of forty-two ; the disease 
came on while suckling; the axillae, groins, and breasts per- 
spired, but there were horny plates on the limbs, and the general 
surface was xerodermatous. A few other cases are scattered 
through literature. In the Sandwich Islands an acquired ichthy- 
osis is common in those who chew the sialogogue piper methy- 
sticum to make " ava." Somewhat more common are local ich- 
thyotic developments, especially in connection with neuritis from 
injury or disease; and Ballet and Dutil have observed it in 
tabetics. But Unna and others refuse to regard these as ichthy- 
* Author's Atlas, Plate XLIII. 



ICHTHYOSIS. 563 

osis, Unna calling them " stagnation keratoses," classing them 
with the indurations seen in association with varicose ulcers and 
elephantiasis nostras. 

Ichthyosis Hystrix is much rarer, and differs in so many ways 
from the other congenital forms that many regard it as a totally 
different affection, but there are connecting links with the com- 
moner variety. Lennhoff in 1893 showed at the Berlin Derma- 
tological Society four sisters: two had slight xerodermia, one 
well-marked ichthyosis, while the fourth showed a transition to 
I. hystrix. It is never general, though it may be widely distrib- 
uted, and occasionally certain parts may be in the hystrix condi- 
tion, while the rest of the skin is xerodermatous, but in the ma- 
jority of cases the intermediate skin is perfectly healthy; more- 
over, the disease is seldom symmetrical, is often unilateral,* and 
sometimes sharply limited on the trunk by the median line. 
It is usual to see it in lines running longitudinally on the limbs 
and transversely on the body. The face is rarely affected, or 
only in a minor degree. 

The lesions vary from small pin's-point-sized, papillary 
growths covered with a horny cap, which forms a nail-head-like 
prominence on the skin, up to warty, dark greenish, vertically 
striated, horny masses, projecting half an inch or more above 
the surface, with a wide base, and truncated, conical shape, like 
limpet shells. When the horny part is soaked or pulled off, 
hypertrophied papillae are brought into view. Inconvenience is 
only experienced when the growths are in awkward positions, 
such as the palms and soles, on which one or more bands are 
common, or when the horny tops are torn off too roughly by 
catching in the clothes, etc.; but they are often shed sponta- 
neously without any pain. 

The extreme instances of widespread horny growths are some- 
times exhibited at shows as " Porcupine men," as in the well- 
known Lambert family, in which it existed in nine males of three 
generations. The warty projections of the first affected were 
cast off periodically. 

Ichthyosis Hystrix Linearis is the minor degree f where 

*Thisisso in my Atlas case; but, as frequently happens, there are 
some patches on the left limb as well as the right. 

■f An interesting series of illustrated cases was published by Stephen 



564 DISEASES OF THE SKIN. 

only a single tract is involved. It is reported from time to time 
under various names, according to the fancy of the author, e. g., 
naevus verrucosus, naevus papillaris, naevus neuroticus unius 
lateris, nerve naevus, neuropathic papilloma, papilloma neuroti- 
cum, etc. This form is rarely hereditary. Many authors deny 
that these cases belong to ichthyosis hystrix. The proofs that 
they do lie in the facts that the individual lesions are exactly 
similar to what may be found in acknowledged cases of ichthy- 
osis hystrix; and as regards distribution, there are all grades, 
from a single line to the widespread unilateral forms previously 
described. 

Unna * is very strongly against their identity, but he restricts 
I. hystrix to cases with horny outgrowths on the plates of the 
higher degree of I. simplex, and in which there is a general 
ichthyosis. This, I think, is too narrow a view, and not in ac- 
cord with clinical experience. Morrow f also differentiates 
them. 

The anatomical cause of this linear distribution is much dis- 
puted; for a long time it was almost an axiom that it was in the 
course of cutaneous nerves, but close investigation showed 
that it did not always correspond with single nerve territories, 
and it was suggested that the lines of Voigt, i. e., the boundary 
lines of the nerve territories, governed the distribution. Others 
said that it followed the lines of cleavage of the skin (vide p. 45) ; 
a fourth theory was that it was in the course of the blood-ves- 
sels; fifth, that it corresponded with the metameric segments 
of the body; and, sixth, that it corresponds with the embryonic 
sutures and follows the direction of growth of the tissues. 

D. W. Montgomery, :[: after arguing out the question, came to 
the conclusion that the sixth theory is the correct one, but in 

Mackenzie in the Ilhist. Med. News, November 3, 1888, p. 123. See 
also Phillipson's two cases setting forth Unna's view, Monatsh.f. ftrak. 
Derm., vol. xi., i8qo. 

* Unna's Histopathology, p. 332. 

f Morrow's article is in N. Y. Med. Jour., January 1, 1898, with chromo 
lithograph. He calls these lesions systematized or linear keratosic 
nevus, but such a name would fit equally well the more extensive I. 
hystrix. 

% D. W. Montgomery. " The Cause of the Streaks in Naevus Linearis," 
Jour. Ctit. and Gen.-Ur. Dzs., vol. xix., 1901, October; numerous 
references. 



ICHTHYOSIS. 



565 



my opinion no one theory is applicable to all cases, and each 
should be studied on its merits. 

Two instances of mental weakness associated with very exten- 
sive cases have come under my notice, and other congenital 




Fig. 27. — Ichthyosis hystrix. X 120. 

The horn has fallen off in preparing the specimen, but the horny layers 
can be seen at a, dipping down into the interpapillary part of the rete, 
which goes deeper than natural into the corium and produces enlarge- 
ment of the papillae. 

defects are occasionally observed. Of these defects of the ear 
are most frequent. 

In an unique unilateral case of Dr. Church the mucous mem- 
brane of the cheek, soft palate, and tongue was affected on the 
same side with papillary growths. 

Thibierge * also reports a case in which the buccal mucous 
membrane was corrugated like a scrotum; it was of opalescent 
tint. The tongue was similarly but more slightly affected. 
There was a high degree of general ichthyosis. But for these 
exceptions it might be said that ichthyosis never affected the 
mucous membranes, the so-called " ichthyosis linguae " being 
an acquired affection of a totally different origin. 

* Annales de Derm., etc., vol. iii. (1892), p. 717. 



566 DISEASES OF THE SKIN. 

I. hystrix * develops quite early, as a rule, six weeks or two 
months being a common period for it to be first noticed, but it 
too may be present at birth. 

Anatomy. — The morbid anatomy of ichthyosis hystrix has been investi- 
gated by Kaposi and myself. Kaposi's observations are quoted in every 
text-book, so I will give my own only. They were made on some warty- 
looking growths upon the flexor surface of the forearm, from a highly de- 
veloped case .f The papillae and their vessels were much enlarged, the Mal- 
pighian cells adjacent to the papillae were normal, but, instead of the layers 
of intermediate cells, which in health fill, or, so to speak, level up, the in- 
terpapillary spaces, and so form a nearly plane surface, on which the horny 
layer rests, the strata of horny cells dipped deeply down into the inter- 
papillary spaces, so that the hyperplastic corneous layer followed the 
outline of the papillary layer, with a comparatively thin layer of rete 
cells intervening. The horny cap consisted of closely adherent, stratified 
layers, with large spaces interspersed here and there. Each of the 
vertical columns sprang from a separate papilla. This description differs 
from Kaposi's, who figures the rete as almost unaltered in its outline. 
Some sections did not show this dipping down of the horny layer to so 
great an extent as others, and so approached the condition which Rind- 
fleisch describes as appertaining to ordinary warts, and which he thinks 
distinguishes them from the ichthyosis hystrix condition; but this is only 
approximately true, as the horny layer in many warts does to some extent 
follow the outline of the papillary layer. Unna's views have been re- 
ferred to already. 

Ichthyosis Congenita. Either after the removal of the vernix 
caseosa, which may be very thick, or, as the skin dries, it is 
noticeably red, smooth, and shining at first, but soon becomes 
dry and rough ; or, more rarely, actual plates are present in the 
most severe cases, constituting the so-called " Harlequin fetus," 
of which there are specimens in University College, Guy's Hos- 
pital, the London Hospital, and the Royal College of Surgeons' 
Museum. The whole surface of the body is thickly covered with 
fatty epidermic plates, some a sixteenth of an inch in thickness, 
which are broken up by horizontal and vertical fissures, and 
arranged transversely to the axis of the body, like a loosely 

* Duckworth, in St. Bart.'s Rep. for 1873, p. 108, reports a case of I. 
hystrix, in which there were red spots at birth, and in three days there 
was " heaping up" upon them. Hutchinson, in his " Lectures on Clinical 
Surgery," vol. i. p. 161, relates a case where there were plates at birth 
and the child survived. 

\CU11. Soc. Trans., vol. xii. p. 181, with plates. 



ICHTHYOSIS. 567 

built stone wall. These fissures, after birth, may extend down 
into the corium, and produce much pain on movement. Owing 
to the stiffness of the skin, and also often from its contraction, 
the eyes cannot be completely opened or shut, and there may 
be ectropion; the lips are too stiff to permit of sucking, and are 
often everted; the nose and ears are atrophied; the toes are con- 
tracted and cramped; and the child, if not born dead, soon dies 
from loss of heat and starvation. 

Where the disease is less severe the child may survive for 
some time. In February, 1890, a male child, one month old, with 
ichthyosis, was admitted under me at the East London Hos- 
pital for Children. The condition was present at birth. The 
child was fairly well nourished and well formed, except the ears. 
The whole skin was dry and hard, as if painted with a thick coat- 
ing of collodion, which was broken up into large thin plates by 
deep sulci, which followed the natural folds. The surface of the 
plates was quite smooth and parchmentlike. The child lived 
three months, but its vitality was low all along. Hallopeau had 
a similar case. Plate IX. of Hebra's Atlas is also of this type, 
and so are two cases of G. T. Elliot of New York, and a case by 
Graas and Torok. In Rona's case, there were discrete reddish 
spots soon after birth which enlarged, in a few weeks there was 
exfoliation, and at two months there was collodionization and 
constant desquamation. The child died at four months, having 
previously had cutaneous suppurations. A child of the same 
parents, set. eleven years, showed the disease at three months 
which increased to a severe condition. 



All these cases are considered by Hebra and Kaposi to be due to 
general seborrhea, and not to ichthyosis (I. sebacea). With this I can- 
not agree. Mr. Sutton* was kind enough to give me some skin from his 
case, and I found enormous thickening of the horny layers (mixed with 
fat), which dipped down into the interpapillary part of the rete, just as in 
ichthyosis hystrix. This part of the rete exhibited considerable increase, 
both vertically and laterally, so that the papilla? were proportionately 
elongated and narrowed, and almost filled with vessels, which were 
dilated both here and at the upper part of the horizontal layer. In the 
scalp the hairs went straight at first, but were lost eventually in the 

* Shown at the Med. Chir. Soc. March 8, 18S6, and published in 
"Transactions" of that year, vol. lxix. p. 291, with colored plate and 
bibliography. 



568 DISEASES OF THE SKIN. 

horny plates. The sebaceous glands were poorly developed, some only 
consisting of a single narrow acinus, or a very small gland with four or 
five acini. There were very few sweat glands in this case, but Caspary 
in his described them as large and numerous. The anatomy certainly 
resembles that of ichthyosis, and 1 consider it a true ichthyosis congenita, 
due to a defect in the keratinizing process in the rete. 

In the collodionized infant above referred to the conditions were great 
and nearly uniform thickening of the homogeneous horny layer, which 
dipped into the infundibular follicular orifices, but did not line them in 
the same way as in the " harlequin fetus." The stratum granulosum 
was well marked, the rete apparently normal, except that the basal cells 
were not differentiated as much as usual. There was scanty lymphocyte 
infiltration in the papillary layer, but the papillae were not enlarged. 
Hairs were present in twos or threes. The sebaceous glands were rudi- 
mentary, while the sweat coils were abundant and well developed. In 
the fat layer the nuclei of the cells were conspicuous. Unna considers 
the condition quite different to ordinary ichthyosis, calls it hyperkeratosis 
universalis congenita, classes it as a stagnation tumor, and says that 
" all the histological phenomena may be ascribed to one cause, viz., to a 
firmer connection of the epithelium mainly limited to the surface," and 
that the skin is therefore too small for the body, hence the fissures 
described on the surface and the ectropia and contractions. His other 
distinctions from ordinary ichthyosis are as follows : 

In ichthyosis ectropion and contractions unknown. (This is incorrect.) 
Ichthyosis has definite regions of predilection. The palms and soles are 
never affected, and the face and neck rarely. (This also is incorrect as 
an absolute statement.) In ichthyosis the affected areas are dry, and it 
is difficult to induce sweating. In I. congenita the hydrosis is normal. 
The anidrosis of Caspary's case, he says, is exceptional. (In my second 
case also there was anidrosis, although the sweat glands were well devel- 
oped.) The follicular apparatus of the skin in ichthyosis is normally 
developed, but plugged in I. congenita atrophic or absent.* 

Many of these distinctions break down on closer examination. Bowen 
considers that there is a special layer of cells analogous to the epitrichial 
layer of certain animals which is present in a three-month's fetus, but 
normally disappears at the seventh month, but in the " collodionized " 
forms of ichthyosis congenita it persists after birth. 

Riecke's f recent observations on two old museum specimens at Leip- 
zig lead him to conclude that I. congenita is a developmental anomaly 
sni generis. The pathological changes are excessive formation of aggre- 
gations of horny cells, as in ordinary ichthyosis, with marked cornifi- 
cation about the hair follicular orifices. The development of the stratum 
granulosum, rete, and papillary layers are practically normal. He dis- 
putes the statements of Unna and others that the number of hairs, sweat 
and sebaceous glands are abnormally high or low. 

* " Histopathology," p. 1157. Some references. 

f E. Riecke, " Ueber ichthyosis congenita," ArcJiiv f. Derm. u. Syph. t 
vol. liv. (1900), p. 289, with colored illustrations and many references, 



ICHTHYOSIS. 569 

G. Finizio,* on the other hand, found the stratum granulosum absent, 
the rete with exaggerated proliferation of variable thickness, the papillae 
large, numerous, and richly vascularized, the derma with abundant lym- 
phoid infiltration, the sebaceous glands well developed, and the sweat coils 
normal. Hans,f while preferring Unna's title, asserts that it is a true 
ichthyosis. It is obvious, with these conflicting statements, that dog- 
matic assertion of the nature of the condition is out of place. 

Etiology. — The disease is congenital, and in many cases, but 
by no means in all, hereditary. The heredity may be direct, 
may skip a generation, or may be through a lateral branch. 
Sometimes only one child in a large family will have it, at an- 
other several children: even in the case of the "Harlequin fetus," 
two, and even three infants have been born of one mother with 
this deformity. The disease often keeps to one sex in a family, 
which may be either of the same or of the opposite sex to the 
affected parent. Thus, I have met with a family of seven girls 
and three boys, the boys being the youngest, in which the dis- 
ease affected four of the girls alternately, beginning at the 
eldest, and also the eldest boy, the father having the same condi- 
tion. Kaposi records the instance of an ichthyotic mother who 
had all five sons ichthyotic, while her three daughters were free. 
This tendency to attack only one sex in a family is also seen in 
xerodermia pigmentosa, a totally different disease; but taken as 
a whole, both sexes are equally liable to ichthyosis, and no class 
is exempt. There is no other known cause for the congenital 
affection, but the neuritic and tabetic origin of the local acquired 
form has been alluded to; while one of my general acquired 
cases was due to semi-starvation, and another was apparently 
from chronic diarrhea. Lutz says that in the Sandwich Islands 
the long use of " ava," a fermented liquor from piper methysti- 
cum, produces the appearance of well-marked ichthyosis with 
some atrophy; while the immediate effect of a debauch of it is 
stupefaction, followed by copious perspiration. 

Pathology and Morbid Anatomy. — Most authors consider that 
there is some congenital defect in the development of the cutis, 
chiefly of the epidermal layer, but according to Unna, the de- 

*G. Finizio, La Pediatria, No. 3, 1900. Abs. La Presse Medicate, 
April 27, 1901, p. 199. 

f Abs. of Hans and Daniel and Bordier's case, Brit. Med. Jour. Supp., 
July 20, 1901. 



570 DISEASES OF THE SKIN. 

feet is acquired, and he only admits a congenital predisposition, 
and regards it as " an infectious hyperkeratosis tending to para- 
keratosis," and compares it to pityriasis rubra pilaris, and 
psoriasis; in short, that it is a low form of inflammation, shown 
by the constancy of an increase of cells, with a tendency to moist 
catarrh, which he would not admit to be eczema, but regards as 
a simple increase of the always present, but latent inflammation. 
At present this view is only held by his own pupils. 

Histologically Unna finds the horny layer thickened (the nuclei being 
absent), at the expense of the prickle layer, which is diminished especially 
over the papillae ; the cells themselves are smaller. The papillae are 
flattened from above, the epithelial ridges from below, like dove-tailing, 
due to increased resistance of horny plate above and diminished resist- 
ance of interpapillary layer below. The granular layer is absent 
completely, so that the prickle cells pass directly into horny cells, 
and as the prickle cells are not removed, pari passu in extreme 
cases they may be reduced to one or two layers. The hyperkeratosis 
extends into the follicular orifices, but does not form papules. The 
sweat pores are unaffected, as a rule, but the lumen of the sweat 
coils is dilated, and the loops resemble the duct, except that the latter 
has a double row of epithelium. The clinical difference seen in extreme 
forms, such as " sauroderma," he ascribes to prickle cell activity (paraker- 
atosis), as well as hyperkeratosis, and these, he says, are the only forms 
which actively inflame and appear eczematous. This is not correct from 
a clinical point of view, as it is notorious that even the mildest forms of 
ichthyosis are extremely prone to eczematous inflammation on very slight 
provocation, and throws doubt on the correctness of his interpretation of 
the histological data, the more so as the almost imperceptible gradations, 
from the mildest to the most severe forms, render it improbable that there 
should be any fundamental differences in the pathology. 

Diagnosis. — The diagnosis seldom presents difficulties, the 
disease dating back from a few months after birth; the dry, 
rough, dirty-looking, deeply-furrowed skin of xerodermia; the 
scales, plates, and the general distribution of I. simplex, and the 
warty growths and streak or nerve distribution of I. hystrix, 
are so characteristic as to leave no room for error, and the date 
of its onset will also distinguish it from those secondary local 
and general conditions which resemble the congenital cases. 
When, however, extensive eczema complicates xerodermia, 
there is a great resemblance to prurigo, the more so as it also 
commences in the first years of life; but the diagnosis between 
these diseases has been given with prurigo. A very mild degree 



ICHTHYOSIS. 571 

of lichen acuminatus is very like xeroderma with keratosis 
pilaris. Its recent development and perhaps a previous attack 
will distinguish it from congenital disease. 

Prognosis. — The prognosis is decidedly bad for its curability, 
but temporary amelioration can always be afforded in ichthyosis 
simplex; and if the patient will take the daily trouble, the skin 
can be kept supple and free from discomfort. In very mild 
cases steady perseverance for years, with judicious treatment, 
has effected a cure, and Hebra mentions a case which got well 
after variola; a congenital case of Elliot got spontaneously well 
in some parts. Ichthyosis hystrix is very hopeless as a rule, 
but I have obtained a permanent removal of the growths where 
the development has not been very great. 

Treatment Internally. — Until lately internal treatment in all 
forms was considered to be absolutely useless, but great im- 
provement has been found to be produced by the internal admin- 
istration of thyroid extract, beginning with a small dose, say of 
two grains for a child of five, and gradually increasing to ten 
grains a day. Although, unfortunately, the improvement only 
lasts a short time after the thyroid is omitted, it is of some prac- 
tical value in aiding the cure of secondary eczematous complica- 
tions. Dr. Buskett of Leeds found nitro-glycerin, one drop of 
a one per cent, solution three times a day, of marked benefit, 
but how long it lasted is not on record. 

Locally. — This must be directed to removing the scales, and 
making and keeping the skin pliable. The first indication is best 
fulfilled by alkaline and bran baths, with friction while in the 
bath, preceded in bad cases by soft-soap inunctions; the removal 
of the scales must be followed by applications of glycerin, oint- 
ments, or lotions, and animal, vegetable, or petroleum fats. 
Almost any fat will do, such as lanolin, lard, cold cream, neat's- 
foot, olive, and almond oils; but cod-liver oil is too disagree- 
able, though very effectual. Kaposi speaks very strongly in 
favor of a five per cent, naphthol ointment in conjunction with 
naphthol soap. 

Whichever substance is selected should be well rubbed in 
twice a day at first, but glycerin lotion will be found the most 
convenient application for the face and hands, in the strength 
of one to ten. Steady employment of these applications will 
soon render the skin quite smooth and supple, and the patient 



572 DISEASES OF THE SKIN. 

* 

will seem to be quite cured ; but this state can only be maintained 
by inunctions two or three times a week and frequent baths, or 
else the roughness very soon returns, and only requires time to 
resume its former severity. Eczema, as a complication, requires 
treatment appropriate to that condition; callosities can be 
softened by strong potash lotions (one to two), or continuous 
applications of soft soap, or removed by salicylic acid plaster. 
The larger growths of I. hystrix should only be interfered with if 
they are in inconvenient positions, and can then be excised or 
scraped with a sharp spoon, followed by Paquelin's cautery, but 
the change is much deeper than it appears, and the destruction 
must be, therefore, more thorough than would be anticipated. 
The smaller papillary growths may be removed by the continu- 
ous application of tar ointment, and though many of them re- 
turn, some will be permanently removed. A more pleasant ap- 
plication, and one which has been more successful than tar in 
my hands, is to paint the growths, after removing the horny 
caps, with a saturated solution of salicylic acid in alcohol. In 
this way I have got rid of large areas of minor growths. 

Keratolysis Exfoliativa Congenita. In 1895 Sangster * re- 
corded a case of congenital exfoliation of the skin. A man of 
twenty-four years first showed signs of desquamation on the 
forehead when three weeks old, it extended and became univer- 
sal at the end of the third year, and had remained in much the 
same state since. The skin was constantly exfoliating and could 
be peeled off in large sheets. There were also tracts of thick- 
ened epidermis divided up in quadrillations. 

The palms and soles were thickened and sodden from hyper- 
idrosis and did not exfoliate. 

There was a great deal of itching, and ecthymatous sor^s 
from scratching were present on the legs. The skin was white 
for some hours, when the loosened skin had been stripped off. 
The hair and nails were unaffected. He compared it with ich- 
thyosis nacreosus. 

Rasch f has had a similar case in many respects, but the skin 
was red, and he suggests " ichthyosis rubra " as its title. 

* Sangster, Brit. Jour. Derm., vol. vii. (1895), p. 37, with photographic 
plate. 

•{•Rasch, " Erythrodermia Exfoliativa Universalis Congenita," Derm. 



HYPERKERATOSES. 



573 



New-born children shed the skin in branny particles or shreds 
or lamellae, occasionally of large size. The process is usually 
complete in a week, but occasionally lasts a fortnight, and H. 
Brauns records a case which lasted sixteen days. 

The above cases appear to be an analogous condition lasting 
into adult life of a normal process of the new-born child, and is 
nearly allied to ichthyosis in its moderate form. 

KERATOSES. 

Keratosis has come recently into use as a generic term for 
diseases in which the chief feature is an overgrowth, or, more 
correctly, an accumulation of horny cells, for the cells them- 
selves do not proliferate, but there is an increased production 
from the prickle cell layer — " the stagnation tumor," of Unna. 
These diseases are of a chronic and benign character as a rule, 
but in middle and advanced life, and in a few instances even in 
early life, epithelioma develops upon them. The most frequent 
precursors of this disaster are corns, senile warts, and arsenical 
keratosis palmae et plantse. 

There are numerous diseases of very variable etiology, pathol- 
ogy, and nomenclature which may be brought under the aegis 
of keratosis, and various classifications have been proposed. I 
give here that of Brooke * as an example, using his own nomen- 
clature. 



HYPERKERATOSES. 



i. General. 

Diffuse : 
Ichthyosis. 
Acrokeratosis. 

Pityriasis rubra pilaris (Lichen 
acuminatus). 
Congenital : 

Hyperkeratosis universalis con- 
genitalis. 



2. Regional. 

Diffuse : 
Keratodermie symetrique des ex- 

tremites (Besnier). 
Erythema keratodes (Brooke). 



Conge?tital : 
Keratoma palmare et plantare. 



Zeitsch., vol. viii. (1901), p. 669. Abs. Brit. Jour. Derm., vol. xiv. (1902), 
p. no. 

* For others by Unna, Dubreuilh, etc., see " Discussion on Keratoses at 
the International Congress of Dermatology in London," 1896, pp. 95 to 
178 of Trans.; also Tommasoli, " Ueber Keratodermitides." Brochure, 
by Voss of Hamburg, 1893. Mibelli, "Etiology and Varieties of Kera- 
tosis," Monatsh., vol. xxiv. (1897), p. 345, etc. 



574 



DISEASES OF THE SKIN. 



i. General. 

Multiplex: 

" Lichen pilaris." 

Keratosis pilaris (in part) (Brocq). 

Keratosis follicularis contagiosa 

(Brooke). 

Porokeratosis (Milbelli). 

r^m^Ar, f Acne comedo. 
L,omeao -j Comedo atrophicans. 

Lichen planus. 



Conge7iital : 
Keratosis congenitalis. 
Multiplex. 
Ichthyosis hystrix (Lambert type). 



2. Regional. 

Multiplex : 

Lichen spinulosus (Devergie). 
Arsenical keratosis palnue et 

plantse. 
Keratodermie en foyers des ex- 

tremites (Besnier). 
Hyperkeratosis subungualis (H. 

Hebra). 
Verruca. 
Callus. Clavus. 
Cornu. 

Onychogryphosis. 
Angiokeratoma. 
Co7igenital : 
Naevus keratodes linearis. 



Keratosis as a complication may be seen in lichen planus 
verrucosus; lupus verrucosus; some forms of elephantiasis, 
etc. 

No practical advantage is gained by those artificial arrange- 
ments which bring together such diverse diseases that they are 
treated of in various sections of the present work. Here it is 
proposed only to include those diseases in which the horny accu- 
mulation is almost the whole disease, or in which the term kera- 
tosis has become generally adopted as part of their nomen- 
clature. We have, therefore, in the first group, warts, corns, 
callosities, and horns, and in the second, keratosis palmaris et 
plantaris (congenital or acquired), and including Besnier and 
Brooke's varieties. 

Keratosis pilaris. 

Porokeratosis. 

Keratosis nigricans (papillomatosus) (Acanthosis nigricans). 

Keratosis vegetans (follicularis) (Darier's disease). 

Keratosis follicularis contagiosa. 

Angiokeratoma. 

Subungual keratoma and onychogryphosis are described with 
nail diseases. 

It is not to be assumed that the diseases have necessarily 
any more intimate relationship than that they have a special 
anatomical feature in common. 



KERATOSES. 



575 



VERRUCA (a wart).* 

Synonyms. — Wart; Fr., Verrue; Ger., Warze. 

Definition. — A small papillary growth with a horny covering, 
variable in size, shape, and consistency. 

Warts are very variable in aspect and development, and have 
names accordingly, which are convenient for description. 

Verruca Vulgaris is the form so common on the hands, espe- 
cially in young people, where it forms a hemp seed to a split-pea- 
sized, hard, sessile, slightly conical elevation, with truncated 
top. 

The upper and greater visible portion of it is horny, and the 
surface is smooth, or studded with minute, moniliform eleva- 
tions, formed by the close aggregation of hypertrophied, horny- 
capped papillae, which, by unequal growth, often break up the 
whole tumor into irregular craggy lobulations. When first 
formed they are the normal color of the skin, but the older and 
rougher they are, the more discolored they become, and are then 
some shade of yellow, brown, green, or even black. They are 
single or multiple, isolated or aggregated into close or loose 
irregular groups, and, while generally seen on the hands, may 
come anywhere. Warts may attack the nail fold and spread at 
the side under the nail, and are then somewhat painful on pres- 
sure. The growth is then flat instead of nodular. 

They occur in great numbers as a symptomatic condition 
in many cases of keratosis nigricans about the buttocks and 
thighs as well as on the hands. One of my patients, although 
under forty, had been subject for several years to ordinary 
looking warts on the palms and backs of the hand and other 
parts, which if left alone became epitheliomatous; one excised 
in the wart stage was seated at a hair follicle. Above a much- 
thickened rete with enlarged papillae was a mass of round bodies 
each with a central dotlike spore and a few layers of horny 
cells above it. 

Verruca Plantaris, the Plantar Wart, deserves separate 
mention, not from any essential difference, but on account of the 

* Author's Atlas, Plate XLYIL, Fig. i, illustrates common and plane 
warts, Fig. 2 senile or seborrheic warts. 



576 DISEASES OF THE SKIN. 

distress and disablement it produces. Its origin is usually trau- 
matic, from some defect in the foot covering, and it is then sin- 
gle in most cases, but I have known a large number to be 
present in connection with keratosis following hyperidrosis of 
the feet. 

The single one is most common at one of the points of pres- 
sure, but it may come anywhere. It may be from a small to a 
large pea in size, and in the central part its component papillae 
are generally discernible, and form soft horny fasciculi with a 
horny ring round, as has been accurately described by Du- 
breuilh.* When the whole is covered by horny epidermis it 
looks like a callosity, from which it is distinguished by the pain 
on pressure. 

Verruca Plana is flat and very slightly elevated, from a pin's 
head to half an inch in diameter, sometimes single, but often 
very numerous. There are two kinds, one affecting children 
chiefly, the other old people. 

In young people (verrucae planae juveniles) they are gener- 
ally quite small, and occur chiefly on the face, especially the fore- 
head, and, to a less degree, on the backs of the hands; they may 
or may not be slightly pigmented, are both disseminated and in 
irregular groups, and occasionally have a unilateral distribution. 
They are often quite square, and bear a very close resemblance 
to the papules of lichen planus in shape and color, being bluish- 
red or yellowish-brown ; but lichen planus is rare on the face and 
scalp, where these lesions chiefly appear. Darier's * histological 
examination of them showed that the chief changes were hyper- 
trophy of all the layers of the epidermis, with elongation of the 
papillae. According to G. Lupis, " The transformation of the 
cells of the Malpighian layer into horny cells appears to be 
delayed, while the overgrowth of the epidermis is apparently 
prior to the elongation of the papillae." He found no micro- 
organisms. Sequeira found them to be acanthomata with very 
little hyperkeratosis. Herxheimer and Marx consider them to 
be quite different to common warts, chiefly because arsenic cures 
flat warts but not the common form, they say — an inadequate 

* Annales de Derm, et de Syph., vol. vi., May, 1895, p. 441. 
f Ann. de Derm, et de Syph., vol. ix. (1888), p. 619; abs. Brit. Jour. 
Derm., vol. i. (1888), p. 82. 



VERRUCA. 577 

reason, in my opinion, since they are often associated in the 
same patient. 

Verruca senilis, Keratosis pigmentosa, Verruca plana 
seniorum, Verruca seborrhoica, is the senile clinical variety, 
but pathologically they are quite different. 

They are seen chiefly on the back and arms, and are generally 
pigmented from brown to black, associated with other signs of 
senile degeneration of the skin, and may itch severely. Al- 
though usually flat, they are sometimes considerably raised 
above the surface, and obviously papillomatous. 

They are said to be very numerous sometimes in cancerous 
patients, and I have seen a very copious crop on the chest, asso- 
ciated with acute eczema, in an elderly woman. They are part 
of the symptomatology of xerodermia pigmentosa. 

These warts have been histologically investigated by Neumann, Balzer, 
Handford, Pollitzer,* etc. The last-named wishes to revert to the old 
term of seborrhoic wart. He has examined eight warts carefully, 
and dismissed Neumann's and Balzer's descriptions as fanciful. The 
discoloration he attributes to the concretion of dirt and fatty 
scales. The stratum corneum is slightly, and the rete considerably, 
thickened. Epithelioid cells are arranged in groups and lines among 
the connective-tissue bundles of the corium throughout its whole 
depth; but the greatest peculiarity, he thinks, is the infiltration of fat 
in the epithelial cells, from the rete to the coil glands inclusively. He 
regards the warts as growths from misplaced embryonic cells, which is not 
very probable, as they are almost invariably present to some extent in old 
people. 

Keratoma Senile, an allied if not identical condition, is not 
infrequent on the face of elderly people, especially about the 
nose and cheeks. It takes the form of a dirty-brown incrustation 
which is firmly adherent, but if forcibly removed a slight papil- 
lary growth, which bleeds readily, may be discerned. 

These papillary growths are liable to degenerate into epitheli- 
oma or a rodent ulcer, and, as they are disfiguring also, are best 
removed. They can be shaved down with a scalpel and then 
carbolic acid crystals applied. Dubreuilh and his pupil Leton- 
turier have drawn special attention to this condition. 

* Brit. Jour. Derm., vol. ii. (1890), p. 109, with plate. He quotes the 
descriptions of the other observers. 

37 



578 DISEASES OF THE SKIN. 

Verruca Digitata. The hypertrophied papillae are here sep- 
arated nearly or quite down to the base, and form fmgerlike 
elevations with a horny cap, the rest being comparatively soft; 
they are aggregated into small groups, or occasionally large 
patches, and occur chiefly on the scalp. 

Verruca Filiformis. These are a small variety of the pre- 
vious form; they are of small diameter, or even filiform, with 
pointed end, not more than one-eighth of an inch long, and 
occur singly, or in small groups on the face, especially the eye- 
lids, and on the neck. 

Verruca Acuminata, or Condyloma Acuminatum. Syno- 
nyms. — Moist or venereal wart; Fr., Vegetations venerienne; 
Condylomes acumines. Gcr., Spitzewarzen; Spitzcondyloma. 

The most common position for these is about the anus, peri- 
neum, in the sulcus, behind or on the glans penis, between the 
labia, and in the vagina, less frequently in the axillae, under the 
mammae when they overhang, in the umbilicus, round the mouth, 
or on the toes. When they are on the free surface, where they 
are dry, they are the color of the normal skin; but in moist situa- 
tions, where they are subject to heat, maceration, and friction, 
they are covered with a whitish or yellowish puriform secretion, 
which soon becomes highly offensive. They are made up of 
closely aggregated projections, which may be acuminate, tufted, 
or club-shaped, sessile or pedunculated, protruding much or lit- 
tle; they grow luxuriantly, increasing by peripheral additions, 
and according to their aggregation, subjection to pressure, luxu- 
riance of growth, and the liveliness of the imagination of the 
describer, imitate various vegetable productions, and get such 
names as cauliflower, frambesia, fungous, mulberry or racemose, 
cockscomb, etc., appended to them. They may grow rapidly 
or slowly, and though parts of them may atrophy, on the whole 
they increase, exhibiting less tendency to spontaneous dis- 
appearance than is generally exhibited by other forms of wart. 
The large rapidly growing warts seen on the vulva of pregnant 
women are an exception, as they generally disappear sponta- 
neously after parturition. A warty condition of the nipples 
also is sometimes seen in pregnant women. 

Verrucose lesions of a more diffuse character are seen from 
time to time under various conditions, such as lupus verrucosus 



VERRUCA. 



579 



and the verruca necrogenica, lichen verrucosus, etc., but there 
are also many cases which cannot be classified in which there 
are little or no signs of accompanying inflammation. 

Etiology. — There is little fact, but much theory, with regard 
to their etiology. All ages and both sexes are liable to them, 
some forms being more common in the young than in the old. 
With regard to the moist form, or verruca acuminata of mucous 
membranes, the evidence that they are produced by irritating 
discharges, especially that of gonorrhea, is pretty conclusive; 
constipation is very often present, but for the rest we know 
nothing. The popular opinion that they are contagious, or at 
least auto-inoculable, has not been quite proved, though Kranz 
thought he had been successful in inoculation with the pointed 
kind; but Petter's more exhaustive and careful investigations 
and experiments were negative. Payne's personal experience 
is the best evidence yet ; he scraped away a w r art with his thumb- 
nail, and one developed under the nail, and others followed on 
the back of the thumb. Moreover, there are some facts in the 
distribution and development of ordinary warts, as well as their 
occurrence in several members of a family, which tend to prove 
the correctness of the popular belief; indeed, Colrat, Cornil, 
Isquierdo, Kuhnemann, etc., have found micro-organisms, both 
cocci and bacilli, and although it is not yet proved that they are 
the morbific agents, it is highly probable that they are so. 

Jadassohn,* after discussing the evidence, agrees that warts 
are transmissible, but could not find the bacteriological proof. 

Anatomy. — The anatomy has been investigated by Barensprung, Vir- 
chow,f Unna, and others with general agreement. Diverse as they are, 
they are all formed on the same principle, the shape and size being deter- 
mined by a central core of connective tissue, containing, and fed by, a 
vascular loop; over this is an epidermic covering of varying thickness and 
cornification. The previous existence of papillae is not essential, a con- 
nective tissue base being all that is required. The pointed forms differ 
from the others only in having more connective tissue, in being highly 
vascular, and while the rete cells are highly developed, the horny cells 
are comparative!)' scanty. 

Kuhnemann 4 who has made careful observations, explains the matter 

"Sind die Verrucae Vulgares iibertragbar ? " V. Deutsch. Dermatol. 
Congress, W. Braumiiller, Wien. 

f " Die krankhaften Geschwiilste," p. 335. 

%Brit. Jour. Derm. vol. i. (1889), p. 328, illustrated with critical review 
of previous observations. 



580 DISEASES OF THE SKIN. 

differently. He says the process is primarily in the epidermis, the 
changes in the form and size of the papillae and the enlarged vessels in 
the papillae and cutis being secondary. The change commences in the 
prickle layer, winch grows upwards and downwards. Then the other 
two layers alter; the granular layer is thickened, and this is the most 
conspicuous change when a wart is first examined; the horny layer is also 
enormously hypertrophied, but in consequence of defective keratinization 
the structure is looser and the nuclei are still stainable. This is the 
most important change, and he would place warts therefore in Auspitz s 
group of parakeratoses. He found numerous cocci and a few short rods 
in the prickle layer, but was unable to prove their significance, and other 
able observers have failed to find them. 

Unna * distinguishes between the common wart and the condyloma 
acuminatum as follows : 

The common wart is an infectious acquired acanthoma on which 
hyperkeratosis immediately supervenes. The condyloma is a pure acan- 
thoma appearing isolated round the mucous openings and on moist and 
seborrhoic areas of skin and tending to extend superficially. The digitate 
warts of the head and the filiform of the eyelids and neck, etc., are here 
included. 

Treatment. — Until recently local treatment alone has been 
employed, but Colrat of Lyons, confirmed by other French 
physicians, has reported that repeated doses of sulphate of mag- 
nesia, 2 or 3 gr. in the case of children, 5ss for adults, three times 
a day, cause the wart to drop off. I can confirm the truth of 
this from my own experience in several cases, though, of course, 
it often fails. Enough sulphate of magnesia to produce two or 
three evacuations a day should be given, and it may be combined 
with the acid infusion of roses, or a carminative. In some cases 
I have thought full doses of nitro-hydrochloric acids have been 
of service. The tincture of thuya occidentalis (arbor vitae), in 
doses of thirty to sixty minims two or three times, is said to be 
curative, but I have no experience of it. Paul Mtiller of Ham- 
burg, and Pullin, are strong advocates of liq. arsenical. TTtij, 
three times a day for an adult, and a quarter of a drop for a child. 
Mansel Sympson is of the same opinion, and says a fortnight's 
treatment is sufficient. Herxheimer and others affirm that it 
is efficacious in juvenile verrucae planae, but not for common 
warts. In verrucae planae I have found thyroid extract effica- 
cious, and in one case the warts on the forehead which had been 
there for years disappeared during tuberculin injections for 
lupus vulgaris. Warts have also disappeared after revaccina- 

tion. 

* " Histopathology," p. 786. 



VERRUCA. 5 8i 

The local treatment varies according to the kind and locality. 
Common warts may removed by the repeated application of 
the nitrate of silver stick, or preferably a saturated solution of 
chromic acid, taking off the black crust every few days; much 
time may be saved by applying salicylic acid plaster until the 
horny part is softened and removable, and then using chromic 
acid. For numerous small flat warts, a saturated solution of 
salicylic acid in alcohol, repeatedly applied, is sometimes quite 
successful; more obstinate cases may require the strong acid 
nitrate of mercury, but these and the other caustics stain the 
part, which is objectionable on the face, so that salicylic acid 
is always worth trying, and if this fails, glacial acetic acid may 
be carefully applied every two or three days, or, as Payne pre- 
fers, a weak acid two or three times a day. Caustic potash, if 
used on common warts, should be limited to the part itself by a 
ring of wax. Frequent painting with equal parts of liq. carbonis 
detergens and spirit is a good plan. Kaposi applies to multiple 
warts of the face sulphur 5v, glycerin giss, glacial acetic acid §iss. 
When warts are small and numerous I snip them off with scis- 
sors, and apply strong carbolic acid to the base with the end 
of a match. I have also removed them by electrolysis. 

The plantar wart, when single, is best removed by electrolysis. 
A flat surgical curved needle, connected with the negative pole 
of the battery, is passed through the base of the wart and kept 
there until the blood-vessels which supply it have been blocked. 
I have had very satisfactory results with this method. Du- 
breuilh curettes them and packs them with antiseptic gauze. 
Eddowes curettes and then applies acid nitrate of mercury, 
which is very painful for some hours. If numerous I should 
shave them off with a sharp scalpel and apply pure carbolic acid 
to the base. 

Digitiform or filiform warts may be ligatured or snipped off, 
and nitrate of silver applied to the base. The acuminate form 
may give more trouble from their extent and vascularity. When 
small and few in number, keeping them perfectly clean and dry 
is sometimes enough of itself; but painting them twice a day 
with liq. plumbi subacetatis, or a solution of perchlorid of iron, 
is valuable. If these fail chromic acid is the most successful, 
and- nitric acid is also good, but both are painful; glacial acetic 
acid is generally successful and not very painful. 



582 DISEASES OF THE SKIN. 

Small pedunculated growths may be removed like the digiti- 
form; when large, by the galvanic ecraseur, or they may be 
snipped off, and styptics, such as the perchlorid or persulphate 
of iron, applied with firm pressure. The bleeding is apt to be 
very great, and unless the growth is in a position readily accessi- 
ble to pressure, the galvano-cautery is the safer plan, cutting 
through the mass slowly with a dull heat. 

The warts of pregnant women should not be operated on 
until after parturition, but great care is required to keep the 
parts clean and sweet, and disinfecting lotions or powders are 
necessary; boric acid, freely sprinkled on, is one of the best 
applications, but iodoform, resorcin, and salicylic acid are valu- 
able in obstinate cases. 



CLAVUS (A nail). 
Synonyms. — Corn; Fr. s Cor; Gcr., Leichdorn, Hiihnerauge. 

Definition. — A hyperplasia of the horny layers, in which there 
is an ingrowth as well as an outgrowth of horny substance, 
forming circumscribed epidermal thickenings, chiefly about the 
toes. 

Corns may be hard or soft; the hard corn is a callosity plus a 
horny peg (the clavus or nail), which, growing downwards, pro- 
duces atrophy of the papillae and a cup-shaped depression im- 
mediately beneath, while the adjacent papillae are hypertrophied. 
Externally there is much less elevation than in the callosity, and 
it is conical, with sometimes a slight central elevation harder 
than the rest; in larger corns there may be more than one such 
horny peg, which, when pressed upon, dig into the cutis, and give 
rise to exquisite pain or dull aching, according to the acuteness 
of the pressure, producing sometimes inflammation and suppu- 
ration. Corns are chiefly situated on the outer side of the little 
toe, the upper surface of the other toes, or on the sole. The soft 
corn is situated between the toes, where it is softened by macera- 
tion, and may exude a small quantity of fluid. It is often more 
painful than the hard ones, and, like them, may suppurate and 
produce painful ulcerations, and even lead to caries. Corns are 






VERRUCA. 583 

sometimes spontaneously painful, and those who have them 
badly often find them veritable barometers for approaching 
wet weather. 

Etiology. — Corns, like callosities, are almost always the result 
of pressure or friction; hence both tight or badly fitting boots 
produce them, and a combination of the two faults in construc- 
tion is the most fruitful cause. Analogous conditions may arise 
spontaneously, as in the case Davies-Colley records: the palms 
and soles of a Hindoo were the seat of disseminated clavus 
nearly all over the surface; there was no history of the circum- 
stances of their formation, but they could scarcely have been 
from pressure. 

Pathology. — According to Rindfleisch, when the pressure or 
friction falls upon a yielding part, a callosity is produced; when 
on an unyielding situation, the pressure is more, concentrated, 
and a corn results; in both cases there is congestion induced, 
which leads to hyperplasia of the horny layers. Small hemor- 
rhages beneath these thickenings are common, and sometimes a 
bursa is formed. 

Treatment. — The first care must be to take off the injurious 
pressure, and to this end the boots should be made to conform 
to the shape of the foot, instead of trying to make the foot con- 
form to the boot. The corn itself may be removed, either by 
soaking it in hot water, and then shaving down the callosity 
with a sharp knife or razor, while the center must be excised, 
preferably with a scalpel. The re-formation must be prevented 
by daily soaping, and wearing a perforated amadou or felt plas- 
ter for some time. Or, instead of cutting, a salicylic acid plaster 
may be worn until the thickened cuticle can be peeled off, and 
then the soaping be used, to prevent renewal. Soft corns should 
have the hard skin removed in one or other of the above ways ; 
careful daily ablution with soap and water should be used, spirits 
of camphor painted on at night, and wool worn between the 
toes in the daytime. All the numerous corn cures, if of any use, 
act on one or other of these principles. 

Duhring recommends the application of a four to eight per 
cent, caustic potash solution after removing the thickened 
cuticle; it must be done cautiously, the part round being pro- 
tected by a ring of plaster. Vigier's formula is also a good one: 
salicylic acid gr. 15, ext. cannab. ind. gr. 8, alcohol Tl\xv, ether 



584 DISEASES OF THE SKIN. 

TTLxl, collodion flexile TT[lxxv. It is to be painted on with a 
brush three times a day for a week, when the corn can be easily 
picked off. 

CORNU CUTANEUM.* 

Synonyms. — Cutaneous horn, Cornu humanum; Fr., Corne de 
la peau; Gcr., Hauthorn. 

Definition. — A horny excrescence of much the same general 
structure as that of animals, but very variable as to shape. 

Horns are very rare in the human subject, but having been 
regarded as curiosities, they have attracted more attention, and 
there is more written on them, than their practical importance 
would otherwise warrant. Lebert is the most comprehensive 
author on this subject. Horns are usually solitary, but may be 
multiple: thus Botge had a case of a man, set. sixty, with six 
horns on his face; and another case, a girl, get. nineteen, in which 
they followed upon an extensive eruption, and were succeeded 
by warty growths, which appeared in the second year of life and 
studded the part of the body below the crest of the ilium, where 
they were of various sizes, while near the navel and on the right 
labium majus they were nearly six inches long; it is probable 
that this was a case of ichthyosis hystrix. 

Human horns closely resemble those of animals, but they 
differ from them in not being of uniform size and shape; they 
are laminated or fibrillated, solid, and of course hard and dry, 
some shade of gray, yellow, brown, green, or black; roundish, 
conical, angular, or flattened; generally twisted or bent, only 
small ones being straight; they may have either a pointed or 
truncated end, but they are largest near the base of origin, 
which may or may not be raised above the surface. They may 
be of any size, from a quarter of an inch to twelve inches long, 

* Literature. — Lebert, " Ueber Keratose oder die durch Bildung von 
Hornsubstanz erzeugten Krankheiten und ihre Behandlung" (Breslau, 
1864), 109 cases. Wilson, Med. Chir. Trans., 1844, vol. xxvii. p. 52, 
and " Dis. of the Skin," sixth edition, p. 796. analysis of 90 cases and 
many references. Memoires de VAcademie Royale de Medecme, June, 
1830,71 cases. Pick, Viertelj. fur Derm. u. Syph., 1875, p. 315, 10 
cases of horns on the penis, with two colored plates; in one case, the 
horn grew two inches in six months. 



CORNU CUTANEUM. 585 

from about an eighth of an inch to between four and five inches 
in diameter; that of Paul Rodriguez,* growing on the side of 
the head, being fourteen inches round, and divided at the point 
into three branches. Their growth is usually slow, but variable, 
and they may either drop off or be knocked off, exposing a red 
raw surface, from which another is liable to be produced. 

The majority of Lebert's, Wilson's, and the French Academy 
lists are repetitions of the same cases. An analysis of these 
shows that nearly half the horns occur on the hairy scalp, fore- 
head, or temples; about one-fifth on the rest of the face, 
especially on the nose; and the remainder on the body in the 
following order: the extremities, especially the thighs, the male 
genitals, chiefly in the sulcus of the glands penis, and the trunk. 
They are only painful when injured, and then may either be torn 
off, or the base irritated into inflammation which may lead to 
their dropping off. According to Lebert, epithelioma f develops 
in twelve per cent.; in rare instances, horns have developed on 
epithelioma. J 

Gussmann records the case of a girl in which horns grew all 
over the scalp, where there was a great deal of rupioid psoriasis. 

Etiology. — Of this our knowledge is meager. Old age is a pre- 
disposing cause, and they are rare before forty, but have been 
seen at any age, from infancy (three cases) to ninety-seven 
years, and are slightly more frequent in females than males. 
The majority start from sebaceous cysts, others from warts, 
and some from scars. Altered toenails sometimes grow ver- 
tically or spirally upwards (Hallopeau). 

Pathology. — They are essentially overgrown warts. They 
always begin in the rete mucosum, or the homologue of it lining 
the glands and follicles; there is always hypertrophy of the 
papillae, and upon these the horn is built up, being composed of 
columns which on section are seen to consist of epidermic 
horny cells, generally without nuclei, arranged in concentric 
laminae, while similar cells, irregularly placed in the interstices 

* New York Medical Repository for 1820. 

f For an example of this see a case by A. Pearce Gould in Path. Trans., 
18S7. 

% A case of a horn growing on an epithelioma of the cheek, in a man of 
sixty-three, was shown by Neumann at Vienna, Annates de Derm, et de 
Syfik., vol. iii. (1892), p. 1316. 



5 86 DISEASES OF THE SKIN. 

between the columns, cement them together. Large vessels are 
formed in the base of the horn. Spietschka * says that no true 
horn can be formed if there are no papillae in that part of the 
skin, but Sutton has demonstrated a case in which a horn grew 
from the cicatrix of a burn on the thigh. 

Treatment. — Soften the horn with water dressings; or if the 
patient is under an anesthetic, tear or cut it off and cauterize 
the base, or apply chlorid of zinc paste or caustic potash, or 
scrape it with a sharp spoon. If the base be not removed, recur- 
rence will take place. Their liability to epitheliomatous 
development renders it important that the removal should be 
early and complete. 

CALLOSITAS. 

Deriv. — Callus, hardened skin. 

Synonyms. — Callosity, tylosis, tyloma, callus, keratoma. 

Definition, — A hard, thickened, horny patch, produced by 
hyperplasia of the horny layers. 

Callosities may be congenital or acquired. The usual ac- 
quired variety is common enough in a greater or less degree, 
and forms on parts exposed to intermittent pressure or friction. 
They come chiefly on the palmar and plantar surfaces, are 
slightly raised, of various sizes, and consist entirely of hyper- 
plasia of the horny layers. This produces the well-known thick- 
enings, with which everyone is so familiar, on the hands of oars- 
men, mechanics (especially smiths), and, less frequently, on the 
fingers of harp and violin players. Purdon drew up a list of 
localities according to occupation, but they do not need any 
more special description. 

An extreme case, in a negro stoker, is recorded by Morrison. f 
A very marked case, also in a negro, came under my care. The 
patient was an omnibus conductor, and was always clinging on 
to a brass rail. Perhaps negroes are especially liable, probably 
because hyperidrosis of the palms is nearly always present. 

* Spietschka, " Histologic des cornu cutaneum," Archiv f. Derm. u. 
Syp/i., vol. xlii. (1898), p. 39. 
\ Amer. Jour. Ven. and Cut. Dis.,vo\. iv. (1886), p. 5, with plate. 



KERATOSIS PALM7E ET PLANTS. 587 

This is a very frequent antecedent in both palmar and plantar 
callosities, and is one reason of their frequency on the feet of 
rheumatoid arthritis patients. 

On the feet they occur generally from ill-fitting boots, and 
are more common in men than women from the nature of their 
occupations, and more frequent in the middle-aged and elderly 
than the young. Occasionally they appear to be spontaneous 
in their development. A curious instance of flat callosities over 
all the first interphalangeal joints came under my notice in the 
person of a very aged mulatto woman, but whether congenital 
or acquired I am unable to say; they were not due to her occu- 
pation. Mr. Sutton informs me that callosities, in exactly the 
same position, are always present in gorillas, as they press upon 
this part in walking. A similar condition exists over the ischial 
tuberosities of baboons and other cynomorphous monkeys. 

Treatment. — When treatment is required, which would not be 
the case when the affection is due to the occupation, the part 
should be soaked in hot water and pared down with a scalpel, 
and then Unna's salicylic plaster continuously applied for a few 
days, when the whole horny part will be loosened and can be 
peeled off. To make it a permanent cure, the cause must be 
avoided. 

KERATOSIS PALM^ ET PLANTiE.* 

Synonyms. — Tylosis; Ichthyosis palmaris et plantaris; Kera- 
toma; Mai de Meleda. 

Definition. — Hypertrophy of the horny layer of the palm or 
sole into a hard plate. 

Although it is etiologically and otherwise different, and patho- 
logically allied to the callositas, it is clinically convenient to 
separate the two conditions. 

Keratosis is a rare affection, and usually congenital, but may 
be acquired. It is symmetrical, and almost always affects both 

* Literature.— Author's Atlas. Plate XLIV. Figs. 3, 4, 5,6 show vari- 
eties of tylosis, as it is there called. The newer name is now adopted, 
as it brings it into line with the other diseases with this designation. 
Also a paper by the author in Brit. Jour. Den?i., vol. iii. (1891), p. 169. 
with cases and colored plate. 



588 DISEASES OF THE SKIN. 

palms and soles, though there may be some variation in degree. 
It is usually confined to the palmar and plantar surfaces, but 
the dorsum may be affected to some extent over the joints. In 
a well-marked case the horny layer of the epidermis is thickened 
into a yellowish translucent, horny plate, from one-sixteenth to 
one-eighth of an inch thick, as a rule quite dry and hard, even 
when, as it usually does, it develops on a hyperidrotic palm or 
sole, but it may be associated with hyperidrosis, and is then, of 
course, sodden. The surface may be quite smooth or it may be 
pitted, and have a worm-eaten appearance. This plate forms a 
uniform layer over the whole palmar surface, with abrupt bor- 
ders without any redness beyond. On the soles the inner border 
of the sole at the arch of the foot escapes; in other words, only 
that part of the foot which touches the ground in walking is 
affected. There is great deepening of the main lines of flexion,, 
and there is naturally some hindrance to free movement, with 
diminished sensitiveness, but no other symptoms in most cases, 
but in some, especially if it arises from an inflammatory condi- 
tion, the horny plate splits into irregular masses, and these fis- 
sures may go down to the corium and be very painful. This is 
especially frequent on the feet and at the border of the thicken- 
ing, and of course interferes with walking.* 

Etiology. — In acquired cases hyperidrosis, whether congenital 
or not, is the most common predisposing cause, and even in 
arsenical cases probably plays an important part. It may also 
arise from the long-continued use of arsenic, which also pro- 
duces hyperidrosis. At the commencement the horny thicken- 
ing occurs round the sweat orifices, at first like lichen planus, 
but later projecting in convex papules, so that the surface is 
nodular; and at this period its arsenical origin may be surmised, 
but gradually the slight depressions between the little nodules 
become filled up, and a level surface is produced, and then the 
tylosis is indistinguishable from the congenital form, unless 
other circumstances point to arsenic as a cause. 

The variety figured by Hebra in his Atlas, and called " tylosis 

* Bassaget describes a congenital and hereditary case from Besnier's 
clinic, in which the palms and soles had a mosaic appearance from super- 
ficial fissures. Aiinales de Derm, et de Sypk., vol. v. (1894). Vomer 
has published a similar case with Histology, p. 1356. Archiv fur Derm.* 
etc., vol. lvi. (1901), p. 3. 



KERATOSIS PALM2E ET PLAXT2E. 589 

palmcc manus verrucosa" * is probably the nodular stage of 
arsenical tylosis. When the knuckles and finger joints are 
affected the thickening is not uniform, but has a pitted aspect, 
and is not so much developed as on the palmar surface. 

Cases associated with pemphigus or dermatitis herpetiformis 
are probably due to the arsenic so often given in large doses 
for those affections. I have also seen it in lichen planus. 
Hutchinson considers senility a predisposing cause. 

Most are congenital and show some change soon after birth, 
but it does not attain its full development for some time. It 
attacks both sexes, though when it shows family prevalence it 
may be confined to one sex in that family. It is often trace- 
able through several generations; thus in my case f and that 
of Horton Dale, \ recorded as before mentioned, it went through 
five generations, in Audry's four, in Unna's § three, and in 
another of mine at least two. In the first named of mine every 
autumn, beneath the palms only, blisters formed of about the 
size of a sixpence, which, if exposed to friction, became very 
large. They formed in succession, the whole epidermis became 
loosened and peeled off, leaving the skin thin and tender. 

The so-called " Mai de Meleda " || is a congenital keratosis 
chiefly, but not exclusively, of the palms and soles. Meleda is a 
small island off South Dalmatia, and probably intermarriage in 
so small a community is the cause of the endemic prevalence of 
the affection, which begins in the first year of life. There is a 
yellow horny plate, already described, with black dots corre- 
sponding to the sweat orifices. There is also ichthyotic thick- 
ening of the skin and deepened creases on the dorsal aspect of 
the wrists and ankles, and occasionally the elbows and knees 
have been involved. At the margin, islets of healthy skin are 

*Hebra's Atlas, Heftx., Taf. 1, Figs. 1 and 2. Fig. 1 represents the 
ordinary form. 

f Loc cit. 

X Brit. Med. Jour., October 1, 1887, p. 718. 

§Unna, " Ueber das Keratoma Palmae et Plantae Hereditarium," 
Viertelj.f. Derm. u. Syph , vol. x. (1882), p. 231, with photograph. 

1 It was first described by Salli in 1826. Lately Hovorka and Ehlers 
have written on it. Arckiv f. Derm. u. Syph., voLxxxiv. (1897), Heft 2 
and 3, Abs. Brit. Jour. Derm., vol. ix. (1897), p. 416. Also vol. x. p. 177, 
abs. of Neumann's paper on " Keratoma Hereditarium," two cases from 
Meleda. 



5po DISEASES OF THE SKIN. 

sometimes surrounded by the keratosis. The upper layers may 
be moist and greasy, and then there is an offensive odor. 
Long-standing cases fissure and break up like the bark of a tree. 

Besides these cases of simple hypertrophy, horny thickening 
of the palms and soles may occur secondarily to inflammations, 
such as eczema, psoriasis, lichen planus, syphilis, etc. These are 
generally patchy, but may affect the whole surface and have 
other differences, which are described under their appropriate 
headings. There remain a certain number of rather rare cases, 
in which, along with the thickening of the epidermis, there are 
some inflammatory phenomena in the form of a ring of ery- 
thema, and perhaps swelling and a sensation of heat at the bor- 
der of the horny portion. This condition may be in patches with 
a broken-up surface, as in the keratodermia erythematosa sym- 
metrica of Besnier; or diffuse, as in the erythema keratodes 
of Brooke. I saw a well-marked case, resembling Besnier's,* in 
a gouty man, set. fifty-six. The condition is unlike eczema 
palmare in appearance, but may be allied to it. The nosological 
position of Brooke's f case is doubtful; he is quite satisfied that 
such cases have nothing to do with ordinary keratosis, but it is 
convenient to consider them here until we know more of them. 
The disease begins, says Dubreuilh, by a red, deeply seated 
nodule, and spreads to form a patch the size of sixpence. As 
it spreads out it gets a thick, horny coating with an erythema- 
tous raised edge round, slightly tender to the touch. It is not 
absolutely limited to the palms and soles, as it may spread to 
the dorsum. 

Treatment. — In congenital cases a cure can, a priori, scarcely 
be expected; but Unna cured five members of the family already 
alluded to, by perseveringly painting on a ten per cent, solution 
of salicylic acid in ether, to which a little fat was added; while 
to the more marked cases a twenty per cent, salicylic acid plas- 
ter, applied as already directed and repeated several times when- 
ever the thick skin re-formed, was eventually successful. A 
similar treatment might be tried for the arsenical and other 
acquired cases, but I have never seen a cure yet, though Hebra 

* International Atlas of Rare Skin Diseases, Plate V., Fig. i. 

f Erythema Keratodes of Palms and Soles," Brit. Jour. Derm., vol. iii. 
(1891), p. 335, with colored plate. Dubreuilh has published a similar 
case, Brit. Jour. Derm., vol. iv. (1892), p. 185. 



KERATOSIS PILARIS. 59 i 

says they get well spontaneously in about a year. In the in- 
flammatory form Besnier produced amelioration by means of 
soft-soap applications and baths, but could never cure it, and in 
the winter it was always worse. My patient improved with ich- 
thyol and salicylic acid applications, but he lived a long way 
from London, and I lost sight of him before he was quite well. 
Brooke produced an apparent cure of his cases with ichthyol 
in three-minim doses internally, and the constant application 
of an ointment of ichthyol and salicylic acid; but one subse- 
quently relapsed. 

In extreme cases it would be worth while shaving off the 
thickened epidermis, and then applying a Paquelin's cautery, so 
as to destroy the papillary layer of the skin. 

KERATOSIS PILARIS. 

Synonyms. — Pityriasis pilaris; Lichen pilaris; Keratosis supra- 
follicularis (Unna). 

Definition. — An accumulation of horny cells, which plug the 
orifice of the hair follicles, and thus form small papules. 

This disease is still called lichen pilaris by some authors, but 
it differs from the lichen class in not being of inflammatory 
origin. 

Symptoms. — It consists of pin's-head-sized convex papules 
of the same color as the normal skin, or of grayish or blackish 
hue from adherent dirt; each of the papules is formed at the 
orifice of the hair follicle, and can be completely picked out by 
the nail, leaving a depression. Sometimes the hair pierces the 
papule, but more frequently it is coiled within or broken off at 
the surface, showing only a dark dot. The adjacent skin is nor- 
mal in color, but often xerodermatous, or even ichthyotic, and 
this, with the hard papules, produces a very rough, nutmeg- 
grater sensation. 

It occurs chiefly on the extensor aspect of the limbs, espe- 
cially the arms and thighs, and occasionally on the trunk; but 
it varies in extent and development, sometimes being scarcely 
noticeable, at others very conspicuous, from the number and 
size of the papules. 

Etiology. — It is most common in those who seldom or never 



592 DISEASES OF THE SKIN. 

take baths, but it may occur in others from the time of puberty 
and onwards, and is sometimes present in a high degree in the 
ichthyotic. 

Anatomy. — Unna * has examined eight cases histologically, and con- 
cludes that the affection is only apparently non-inflammatory ; that 
it is a chronic inflammation localized at the follicular orifices, and that 
the "apparently non-inflammatory form has something of the same re- 
lation to the evidently inflammatory as pityriasis capitis has to seborrheic 
eczema of the scalp." 

The primary change is in the horny layer of the follicular entrance. 
This horny layer runs completely over the follicular entrance, blocks it 
and the exit of the hair, which is therefore compelled to undergo spiral 
twisting and " hold the yielding walls of the follicular neck asunder." 
The resistance to the escape of the hair produces a permanent irritation 
and hypertrophy of the arrector muscles, and clinically produces a chronic 
cutis anserina and anatomically a bending of the hair follicle. There is 
always slight and sometimes pronounced perifollicular and interfollicular 
new formation of connective tissue cells, and in about a third of the 
cases, permanent dilatation of the vessels. 

Diagnosis. — It is in many respects like a late stage of true 
lichen pilaris, but it lacks the central horny spine of that affec- 
tion, is essentially chronic, and there is no inflammation at the 
commencement. It closely resembles cutis anserina, but that is a 
transitory condition, lasting very little longer than the cold or 
fear which produces it, and its papule cannot be removed by 
the nail. 

From lichen scrofulosus, and the papular syphilid with similar 
characters, it may be distinguished by the positions, the greater 
prominence and hardness of the papules, and by the constitu- 
tional condition present with these two inflammatory condi- 
tions. 

Treatment. — This is much the same as that of xerodermia, viz., 
alkaline and vapor baths, soft-soap inunctions, followed by 
warm baths; or the inunction of oily substances of various 
kinds may be rubbed in, in the same way as is described under 
Ichthyosis. 

* " Histopathology," p. 287. He compares his observations with mine 
on lichen pilaris, but mine refer to a totally different disease, although 
the two affections are often called by the same name of lichen pilaris. 






POROKERA TOSIS. 5 93 

POROKERATOSIS (Mibelli).* 

Synonyms. — Hyperkeratosis eccentrica (Respighi) ; L'hyperker- 
atose figuree centrifuge atrophiante (Ducrey and Respighi). 

Mibelli and Respighi in 1893 described simultaneously a form 
of disease which they both considered to be a hyperkeratosis, 
that is, an overgrowth of the horny layer, and Mibelli, finding 
that the horny change was especially marked at the sweat ducts, 
called it Porokeratosis. No less than four cases have been 
described by these two observers, two of the cases by both 
authors; and others have been published by Hutchins, Reissner, 
Max Joseph; Gilchrist (two in one family), Dubreuilh, Wende, 
Basch, Ducrey and Respighi together, their case also affect- 
ing mucous membranes; Kullack of Berlin (three cases). 
Galloway showed a case at the Dermatological Society of Lon- 
don in June, 1901, the only one shown there up to that date, 
but Perry has shown one since then.f 

Moderate-sized lesions are circinate, crescentic, or gyrate, 
but with a sinuous outline. They are from a third of an inch in 
diameter to an inch or two when single; but compound lesions 
may extend with some breaks of continuity for the length of 
a limb segment, as in Mibelli's case in the International Atlas, 
where it extended on the extensor aspect the whole length of 
the forearm, and back of the hand nearly to the knuckles, gyrat- 
ing in a most complicated outline with the central portion clear. 
It took five years to attain these dimensions. Confining atten- 
tion to a medium-sized lesion, the border is raised about one- 
twelfth of an inch above the normal skin, rather abruptly, and 

* Literature. — V. Mibelli, International Atlas, No. 9, 1893. For the 
remaining literature see Wende, Amer. Jour. Cut. and Ven. Dis., vol. 
xvi. (189S), p. 505, who gives a new case and references to date, except 
Ducrey's and Respighi's important and highly illustrated article in 
Annates de Derm, et de Syfik., vol. ix. (1898), p. 609, on " L'Hyperke- 
ratose figuree centrifuge atrophiante." Useful abstracts are Mibelli's 
first paper, Annates de Derm, et de Syph., vol. v. (1894), p. 128. Res- 
pighi's 1895 paper, Brit. Jour. Derm., vol. vii. (1895), p. 367. Max 
Joseph's paper, Brit. Jour. Derm., vol. ix. (1897), p. 366. Gilchrist's, 
Amer. Jour. Cut. Dis., vol. xv. (1897), p. 386. 

f Payne showed a case on October 12, 1892, which was probably poro- 
keratosis, but it was not recognized at the time. 
38 



594 DISEASES OF THE SKIN. 

slopes off towards the center. The outer portion of the border 
is studded with miliary prominences, while the upper surface has 
a fine linear horny layer upon it, and occasionally isolated or 
grouped miliary oval concretions. There is no sign of inflam- 
mation, the color being almost the same as the normal skin, 
but more frequently of a semi-translucent yellowish tint, due 
to the horny change in the epidermis. Mibelli speaks of the 
color being in different lesions, yellowish, dirty yellow, red- 
brown, deep red with a violet tint, a little browner or very little 
different from the normal skin. 

Respighi lays great stress also on the presence of a horny 
linear projection, either continuous or divided longitudinally by 
a narrow furrow, with a horny border. It was well marked in 
Galloway's case. 

The tendency is to extend very slowly at the periphery, clear- 
ing up more or less completely in the center, so that the in- 
closed skin may be normal, atrophically depressed, and without 
hair or sweat, but it is very exceptional for any lesions to 
undergo complete involution (one case of Mibelli's). The dis- 
ease, when once it is established, is very slowly but continuously 
progressive as a whole for an indefinite number of years, or 
throughout life. Wende's case began as a small rough scaly 
plaque on the back of the hand, which soon attained to the size 
of a pea, and looked like an ordinary wart. After about a year 
it suddenly developed into a small ring, and then spread periph- 
erally. The irritability decreased with this extension at first, 
but increased again afterwards. During the last two years there 
were sudden colorless evanescent swellings round or even away 
from the lesion, but confined to the affected area. Hutchins' 
case affected the palm as well as the back of the hand. 

Positions. — The favorite positions are the back of the hands, 
including the fingers, and extending up the wrists and rest of 
the arm, and less frequently the corresponding portions of the 
lower limb. It also attacks the neck, especially at the sides and 
nape; the face and scalp, these positions ranking next in fre- 
quency to those of the hands and wrists. In exceptional cases 
it has involved the body, the buccal mucous membranes, and the 
nails. 

Besides these most typical lesions, Ducrey and Respighi de- 
scribe: 



POROKERATOSIS. 595 

1. Miliary projections, either acuminate or with a punctiform 
umbilication at the summit, and with a peripheral collarette. 

2. Miliary papules, flat or slightly convex, bordered with a 
very fine horny collarette. 

3. Patches, hard over the whole area, of variable size, inclosed 
by a furrow with a horny raised border, which may even project 
above the area it incloses. The furrow is sometimes only visi- 
ble when the patch is bent. 

4. On the mucous membranes there are white opaline spots 
with white projecting border, or uniformly opaline all over. 

Etiology. — Both sexes are liable to it, but hitherto the ma- 
jority have been males. It may commence at any age from one 
to two years and upwards. It shows a family prevalence, and 
in Gilchrist's series of cases there were eleven persons affected 
in four generations of the family. 

Pathology. — This is unknown. Respighi tried in vain to find 
a microbe, but Wende ; in one out of many inoculation experi- 
ments, was apparently successful in reproducing the disease in 
the patient already affected within ten days of inoculation, and 
the microscope, after excision of the small patch, which was 
allowed to remain ten weeks, seemed to confirm the truth of 
the supposition of identity. It is, however, in its most promi- 
nent features a keratosis with horny plugs, especially marked 
at the sweat orifices, though Ducrey and Respighi's observation 
that the buccal mucous membrane could be implicated, shows 
that a sweat pore is not essential to the process. 

Anatomy. — This has been studied by almost all those who have 
recorded cases. It maybe summed up as follows: 

The changes are almost entirely epidermal. The horny layer is very 
much increased in thickness and density, especially in the middle layers; 
the prickle cell layer is also much thicker, especially in those parts where 
the hyperkeratosis is marked, and the interpapillary cones are thicker; 
and a mass of horny cells extends from the base of the interpapillary cone 
to the surface. 

The stratum granulosum was found by Wende to consist of five to eight 
layers. 

The sweat pores are filled with horny cells, and their orifices crowned 
with a horny incrustation; the sweat coils are more or less atrophied. 
The superficial layer of blood-vessels is dilated, and there is a multipli- 
cation of leukocytes especially near the coil glands, but it is not a con- 
spicuous feature. Respighi confirms Mibelli in that the horny change is 
most marked at the orifices of the tubular glands, but also adds those of 
the acinous glands. 



596 DISEASES OF THE SKIN. 

In the anatomy of the buccal lesions there is great dermic infiltration, 
and very considerable development of the papillary body, so that Ducrey 
and Respighi were led to consider it of dermic origin, and not epidermic, 
as Mibelli and others consider it to be. 

Diagnosis. — The most conspicuous features are the presence 
on the exposed parts, hands, wrists, face, and neck, of ringed or 
gyrate patches of very variable size, with a slightly atrophied 
or normal center, and an abruptly projecting border with a 
sinuous outline. The whole is suggestive of a horny and there- 
fore epidermic development, inflammatory signs being absent. 

It is not like any other dermatosis with which I am ac- 
quainted. 

Prognosis. — Slow progressiveness is the rule, but not at a 
uniform rate. Involution is very rare. 

Treatment. — If the lesions are small in size and number, they 
might be excised, but experience has shown that, unless removal 
is radical, the disease returns on the site of removal. 

Salicylic plaster might be applied, and after removal of the 
horny portion, strong acid nitrate of mercury pressed in with a 
wooden match to a small area at a time. 

G. H. Fox * has described a form of axillary porokeratosis, of 
which he has seen two cases. The eruption consisted of numer- 
ous firm, smooth, rounded papules about a line in diameter of 
normal color, except when the intense itching led to excoriation. 
The lesions were chiefly in the axillae in the woman and entirely 
there in the man. In the woman there were also some papules 
on the pubes, but these did not itch much. Eleven months of 
the most varied treatment failed to relieve the distressing pru- 
ritus. Fordyce found microscopically a hyperkeratosis round 
the sweat and hair orifices with acanthosis down to the corium, 
mechanical dilatation of the coil glands, and some chronic in- 
flammation of the derma. The general microscopical appear- 
ances were like porokeratosis. 

* Amer. Jour. Cut. Di's., vol. xx. (1902), p. 1. 



KERATOSIS NIGRICANS. 



597 



KERATOSIS NIGRICANS.* 

(Papillaris.) 

Synonyms. — Acanthosis nigricans; Dystrophic papillaire et pig- 
mentaire (Darier); Dystrophic papillo-pigmentaire (Hallo- 
peau). 

Definition. — A general symmetrical disease, characterized by 
hard and soft papillary growths, keratosis, and pigmentation 

This is a very rare disease, of which there are only about 
thirty cases on record. 

It was first described by Unna's pupils, Pollitzer and Janow- 
sky, in 1890, as acanthosis nigricans, and soon after by Darier. 
Its striking characters partly account for the number of cases 
since reported. I have chosen the name proposed by Kaposi, 
as it represents a clinical fact, instead of an incorrect patholog- 
ical theory, and brings it into line with other keratoses. 

The mode of onset varies. In some pigment changes are first 
noticed on the neck or face. 

In one of my own cases, and in others also, a sudden out- 
break of common warts appeared on the back of the hands, or 
they have begun on the thighs. In a third set itching inside the 
thighs was the first symptom. In a fourth a discomfort in 
the tongue and mouth marked the onset, and was an early 
symptom in many cases. 

Whatever may be the mode of commencement, the other 
symptoms usually develop symmetrically, rapidly or even simul- 
taneously, and over a wide area, but showing a marked prefer- 

* Literature. — Author's Atlas, Plate LIV., Acanthosis Nigricans; also 
Internat. Atlas, Plates X and XL , Pollitzer and Janowsky's cases. Darier, 
"Dystrophic papillaire et pigmentaire," Annates de Derm., vol. iv. 
(1893), p. 665, and vol. vi. (1895), p. 97. Cases by other reporters, loc. cit.^ 
vol. iv. (1893), P- 876; vol. vii. (1896). pp. 1276. 1282; vol. viii. (1897), pp. 
210, 232 (abs.), and p. 808 (abs.); vol. x. (1891), (abs.) of two cases. 
Kuznitzky, Archiv f. Derm. u. Syph., vol. xxxv. (1896,, with refer- 
ence. Spietschka. ibid., vol. xliv. (1898), p. 247. Burraeister, vol. xvii. 
(1899), p. 343. Morris, Med. Chir. Trans., vol. lxxvii. (1894), colored 
illustrations of remarkable case. Barski's case is published in Trans, of 
Moscow Congress, 1899, P- 575; at pp. 186, 192, are communications by 
Heuss, Hallopeau. and Wolff. Hiigel from Wolff's clinic, R. Schultzel et 
Cie., Strasburg, 1898, and references. 



598 DISEASES OF THE SKIN. 

ence for certain regions. These are the neck, groins, axillae 
and flexures generally, the back of the hands, the palms, the face 
and the orifices of the mouth, anus, vulva, ears, and even the 
nostrils and eyelids. 

On the trunk the umbilicus, mid-sternum, the flanks, and 
interscapular regions are the most frequently involved, but there 
is no part exempt. On the lower limbs there is usually not 
much, below the lower and inner half of the thighs, except the 
popliteal space and the dorsum and sole of the foot. 

Taking them in the above order, the neck is found to be, not 
only pigmented from a brownish to bister tint, or even black, 
but owing to the thickening of the epidermis the natural lines 
of the skin are much exaggerated and the appearance of lichen- 
ification, but without induration, is produced. 

Soft papillary growths from a hemp seed to a pea are numer- 
ous, and there may be seborrheic warts at and below the 
nucha, where the thickening is usually most pronounced. 

The axillae show these changes in a higher degree, the color 
is a grayish or sooty-black in the center, shading off at the 
margin and down the sides. The thickening now amounts to 
deep folds traversing the axillae obliquely, while shallower lines 
at right angles break up the ridges in squarish masses of papil- 
lomatous appearance. In Morris' case, as the disease advanced, 
a raw-looking red mass produced through the black part. Hard 
as well as soft warts may be numerous, not so much at the 
axillae themselves, but beyond them, where the skin is no longer 
moist. The groins are very much like the axillae, but here the 
disease reaches its highest development, the genitalia being 
often of a sooty black. The anus is frequently involved with a 
warty growth arid black pigmentation round it; the umbilicus 
presents a similar aspect, a band of pigmentation often extends 
from the latter transversely or vertically. In my own and other 
cases there were numerous warts on the inside of the thighs. 

On the back of the hands, wrists, and halfway up the fore- 
arms, there are often numerous warts indistinguishable from the 
common kind, which coalesce towards the wrists into diffuse 
broken-up horny masses, and the rest of the skin is obviously 
thickened in the upper layers and traversed by the deepened 
natural lines, deepest transversely. In my case the flexor sur- 
face as well as the extensor aspect of the wrist was affected. 



KERATOSIS NIGRICANS. 



599 



Over the knuckles and finger-joints the skin presents a gran- 
ular appearance due to minute horny scales. The color is usu- 
ally only brownish, but in Janowsky's case was blackish and 
with exaggerated quadrillation, it looked like shark skin. 

The palmar surface shows diffuse horny thickening of a trans- 
parent yellowish tint, the center of the palm being the least 
affected. The nails often show damaged nutrition, in the shape 
of longitudinal striae, transverse white bands (my case), pitting 
and brittleness at the edges, and Cohan's case had " spoon " 
nails and the hair fell out. The flexures of the elbows and 
knees, if affected, show the same obliquely transverse ridging 
and pigmentation, with or without warts, as on the axillae, but 
in quite a minor degree. On the trunk there is often diffuse 
black pigmentation, over the lower half both back and front, or 
it may be in the upper half only, or nearly all over. The nipples 
are not only discolored, but may have a warty development 
round their base, which makes them painful when pressed upon. 
On the face there may or may not be dusky or brownish pig- 
mentation either diffuse or round the orbits, but the most strik- 
ing changes are round the commissures of the lips and inside 
the mouth. 

In Pollitzer's case there were remarkable papillary gray- 
black growths at the angles of the mouth as large as the tip of 
the finger. This is exceptional, but slight developments are not 
uncommon. Inside the lips the mucous membrane is thickened, 
velvety, and granular; the buccal mucous membrane shows a 
similar change, but with a whitish surface like lichen planus ; the 
gums are sometimes affected; the palate, both soft and hard fre- 
quently, have the thickening and granulation very marked, 
sometimes warty; at the anterior half the pharynx and epi- 
glottis have been exceptionally involved (Janowsky). The dor- 
sum of the tongue may be profoundly affected; in some of the 
cases it was covered with long filiform projections two to three 
millimeters long, which could be bent or separated like hair 
(Darier and Boeck). In Pollitzer's and Morris' cases the tongue 
was deep red, fissured, and condylomatous; in Janowsky's the 
under surface also was affected, but in his case the whole oral 
mucous membrane was profoundly affected. In my own case 
the surface of the tongue looked as if coated with a bluish-white 
paint, and there was only slight thickening of the surface, and 



600 DISEASES OF THE SKIN. 

one of the first symptoms was a feeling of roughness on the 
tongue and palate and loss of taste; in Pollitzer's case the 
tongue and mouth were painful; in Hallopeau's case the tongue 
felt swollen. 

In a few cases the edges of the nostrils have been affected 
and warts at the naso-labial fold are common; in Janowsky's 
case there was hyperplastic rhinitis. In several instances millet- 
seed or filiform papillomata have been seen on the edges of the 
eyelids, some pierced by cilia and aggregated towards the com- 
missures (Darier's case), and in Janowsky's case the lashes fell 
out. In Couillaud's case the palpebral conjunctiva was granu- 
lar. In Janowsky's and Morris' cases the external auditory 
meatus was filled with warts. Some cases have had general 
but moderate enlargement of the lymphatic glands. There is 
often falling of the hair to a considerable extent, but in Morris' 
case, a woman of thirty-five, there was a thick growth of white 
hair on the face, and to a less degree on the chest and ab- 
domen. Of course all these symptoms are not seen in high 
development in any one case, but a large proportion of them 
are associated in a moderate degree; thus in my Atlas case the 
mucous membranes were unaffected, and the hands and feet only 
very slightly involved. 

It is a question whether certain ill-developed cases should be 
included, such as Pringle's,* where there was itching and pig- 
mentation for years before papillary growths appeared; or 
Du Casters,f where there was itching of the legs and thighs, 
and then the skin on the abdomen got hard and dry, with a 
lichen-like condition of the skin with pigmentation. Leslie 
Roberts' and Joseph's cases can certainly be excluded; but there 
is a case, reported by myself in 1881, which should, I think, be 
included — a young and vigorous man of twenty-two, in whom 
the pigmentation and soft papillary growths were highly de- 
veloped, but the hands and mucous membranes were free. 

Morris showed on February 8, 1899, at the Dermatological 
Society a case of an elderly woman, in whom, soon after an 
operation for the removal of some tumor on the shoulder and 
glands from the axillae, there appeared extensive highly crusted 



* Brit. Jour. Derm., vol. ix. (1897), p. 76. 

f Du Castel, Annates de Derm, et de Syph., vol. vii., 1896. 



KERATOSIS NIGRICANS. 60 1 

warty growths, which extended over a large area back and front, 
on and above the breasts, reaching nearly to the axilla; in the 
right axilla itself was a moist papillary growth very like an 
exaggerated keratosis. 

The explanation which occurred to me was that the opera- 
tion produced nerve injury, analogous to that of the abdominal 
sympathetic which is supposed to account for keratosis nigri- 
cans. 

Couillaud thinks that papillomatosis may occur without pig- 
mentation in keratosis nigricans. Certainly, as in Rasch's case, 
papillary growths may occur in the axillae, etc., without pigmen- 
tation, but whether the pathology is essentially the same cannot 
be determined, and it is better for the present to keep such cases 
apart from the pigmented ones. 

Etiology. — The disease is rather more frequent in women. 
Two-thirds of the cases occur after the age of forty-six, the 
oldest so far was seventy-two (Hallopeau), the youngest thirteen 
(Barski), and in this boy it began when only two years old. 
Isidore Dyer * had a case of an Italian child, set. seven, but the 
date of origin was unknown. In Pringle's case, a woman of 
twenty, the lips were affected as long as she could remember. 
In my first case it came out suddenly at the age of fourteen; 
the age of eighteen also has been recorded. In all these young 
cases the general health has been undisturbed, except in Paw- 
lof's f case, which began at eighteen, six years after a fall and 
injury to the epigastrium; but in the older ones the case is far 
different, and serious visceral disease has been present in a large 
proportion; of these, cancer of the stomach and liver are the 
most frequent. In my Atlas case hypertrophic cirrhosis had 
been diagnosed, and the skin condition had been going on 
twelve years, and the papillary growths had become much 
larger. 

In Janowsky's case exposure to great heat was the appar- 
ent cause, and it got well spontaneously. In one of mine expo- 
sure to great cold brought it on, and it had persisted for eight 
years without other changes. In other cases no clew to its 

* New Orleans Med. and Surg. Jour., October, 1898. 

f Pawlof. Monatsh. f. pratk. Derm., vol. xxxiv. (1902), p. 269, with 
some references and microscopic plate. Abs. in Brit. Jour. Derm., vol. 
xiv. (1902). 



602 DISEASES OF THE SKIN. 

origin could be obtained. In one of my cases the patient died 
from exhaustion from pyloric obstruction, but no cancer could 
be detected during life; nevertheless, his skin improved, the 
warts disappeared, the mucous membranes got nearly well, and 
the pigmentation less. There was no autopsy. 

Pathology. — The most plausible view is that there is disturb- 
ance of the abdominal sympathetic from pressure of cancerous 
growths or from other cause, but no anatomical proof has been 
furnished. As far as the skin changes are concerned, all are now 
agreed that it does not originate in the prickle cell layer, and 
therefore it is incorrect to call it acanthosis, since the horny 
layer and papillary portion of the cutis are most concerned in 
the process, and Darier, Pawlof, and others consider that the 
papillary change is the primary one. 

Anatomy. — The main changes are the increased thickening of the horny 
layers and stratum granulosum, and to a slight degree of the prickle cell 
layer; enlargement of the papillae of the skin from down-growth of the 
interpapillary processes, while the soft and hard papillary growths of the 
skin are of the usual structure. In Hallopeau's case increase of the 
elastic fibers was a marked feature, while Boeck found them diminished, 
and described the pigmentation as deepest in the three deepest layers of 
the epidermis, chromatophorous cells being abundant. Further details 
may be found in Darier's, Boeck's, and other articles. In my own case 
of 1881 the condition is shown in the accompanying plates. 

Diagnosis. — The most striking features are the presence of 
pigmentation in the neck and flexures with papillomatosis, espe- 
cially in warm and moist positions, a widespread keratosis with 
warts, discrete and diffuse, and analogous changes affecting all 
the visible mucous membranes. 

The disease which resembles it most closely is keratosis 
vegetans, or Darier's disease, and the comparison between the 
two affections is given under the latter. 

In Addison's disease the localization and tint of the pigment 
is somewhat different; there is pigmentation of the mucous 
membranes and an absence of keratosis and papillomatosis. 

Prognosis. — Although one case has got well spontaneously, 
and another after the removal of a cancerous uterus, and one 
or two have become ameliorated as far as the skin is concerned, 
a cure can scarcely be hoped for in most cases by direct means. 



KERATOSIS NIGRICANS. 603 

Where there is visceral disease, the effect on the patient's life 
and health will depend on that. 

Treatment. — If a cause be detected, such as cancer of the 
pylorus or elsewhere, and if it is in such a position that it can 

6 




c 

Fig. 28. — Skin of abdomen. X 120. a, corneous layer dipping down 
into the rete mucosum; b, rete thinned; c, pigment in the deep layers 
of the rete. 

be removed, the skin will get well, in all probability, as hap- 
pened in Spietschka's cases, where, a few months after the re- 
moval of the uterus for deciduoma malignum, the skin got quite 
normal. Otherwise nothing can be done except to remove any 



Fig. 29.— Two papinary growths in the skin of the neck. X 60. a, 
corneous layer; b, rete mucosum; c, pigmented layer; d, downgrowth 
of the rete between the papillae. 

warts or papillary growths which, from their position, are a 
special annoyance. 

C. Boeck thought his case improved under the administration 
of suprarenal capsule extract, but the fact that no disease of 
the capsules has ever been found does not lead one to expect 
much from this treatment. 



604 DISEASES OF THE SKIN. 

KERATOSIS VEGETANS.* 

(Follicularis.) 

Synonyms. — Darier's disease; Psorospermose folliculaire vege- 
tante (Darier); Keratosis follicularis (White); General 
hypertrophy of the sebaceous system (Lutz); Ichthyosis 
sebacea cornea (E. Wilson). 

Lutz and White of Boston gave the first clear description of 
this disease, but Darier's work on its pathology brought the 
subject into general notice. 

It is very rare, only about twenty-five cases being on record 
up to 1902, and it is probable that some of these cases were 
really examples of keratosis nigricans, as there are so many 
remarkable resemblances between the two affections. 

Symptoms. — The disease begins most commonly on the face 
or head, less frequently on the trunk, but ultimately the regions 
chiefly affected are the scalp, face, feet, the neck, back of the 
trunk, especially near the spine, the flanks, flexures, anus and 
vulva, axillary and inguinal regions; in the last part, it reaches 
its acme of development. The symmetry is striking, and the 
distribution, as a whole, is the same as keratosis nigricans. 

* Literature.— Intern. Atlas, Plates XXIII., XXIV., and XXV. Schwen- 
inger and Buzzi's case. Darier's Histology in "Psorospermose folli- 
culaire vegetante," A fin. de Derm, et de Syph., vol. x. (1889), p. 597 — 
a histological study, with plates. Thibault's "These de Paris," 1888, 
with the same title, gives the clinical account of Darier's case. " Ker- 
atosis Follicularis," J. C White, Amer. Jour. Cut. and Gen.-Ur. Dis., 
vol vii. (1889), p. 201, and 1890, second case, p. 13. Lustgarten, loc. cit., 
January, 1891 — this was the case recorded by Bulkley in New York 
Med. Jour., with a review of the subject. •" Vier Falle von Darier'scher 
Krankheit," C. Boeck, Archiv f. Derm. u. Syph., vol. xxiii. (1891), p. 
857, with histology. " Ueber die Darier'sche Dermatose," Buzzi und 
Miethke, Monatsh., vol. xii. (1891), pp. 9 and 59. Brit. Jour. Derm., vol. 
iii., 1891, gives abstract of two Russian cases, "Ichthyosis Sebacea 
Cornea" in " Diseases of the Skin," 1897, p. 358, by E. Wilson. " Con- 
tribution a l'Etude de la Psorospermose Vegetante," T. de Amicis, " Bib- 
liotheca Medica," D. ii. Heft 3, 1894, plates. J. T. Bowen, "Keratosis 
Follicularis," Amer. Jour. Cut. Dis., vol. xiv. (1896), p. 209, gives refer- 
ences to 20 cases. E. Doctor, Archiv f. Derm. u. Syph. (1898), p. 323, 
gives references to date, though his own two cases should be excluded in 
my opinion. Gilchrist, The Johns Hopkins Hospital Reports, vol. i. and 
reprint. 



KERATOSIS VEGETANS. 605 

One of White's cases began as dry brown patches at the sides 
of the forehead, others as pin's-head smooth firm papules of 
normal color, which enlarged and became slightly hyperemic; 
in both stages they resembled keratosis pilaris. When still 
larger they become hemispherical with polished hard covering, 
varying in color from dull red to purplish dusky red, brown, 
brownish-black, and somewhat resemble lichen planus. The 
most common of the primary lesions is a lentil to pea-sized 
papule of a dirty red color, with a firmly adherent grayish- 
brown, black, or gray, horny crust inserted into it. This little 
sebaceous horn on removal leaves a conical, funnel-shaped 
depression in the little papule, which is seated at the pilo- 
sebaceous follicle. Similar f-lugs may be embedded in the skin, 
without a projecting portion above the surface. These plugs, 
whether above or below the surface, can be squeezed out by 
the thumbnails like the contents of molluscum contagiosum, 
which they most nearly resemble, but they are not translucent, 
and are not inflammatory-looking. The lesions are discrete at 
first, but increase in numbers until they become confluent in 
some parts, and the patch is then covered with a brownish, 
greasy layer, rough to the touch from the irregular projections. 
The disease progresses slowly as a whole, but there may be 
acute exacerbations, when a fresh area of considerable size may 
be invaded with innumerable non-inflammatory papules with 
very small gray crusts; thus the whole upper limbs were affected 
in a single attack in Darier's case. 

As time goes on the papules increase, not only in numbers, 
but in development, forming reddish elevations, with a plugged 
apex or crateriform opening. The horny crusts sometimes 
reach a considerable size; in one of White's cases one horn pro- 
jected three-quarters of an inch. 

The base of the papule may be denuded of its epidermis, and 
sebum or sebaceous pus squeezed out. Large masses or 
tumors may be formed by confluence, especially on the scalp, 
face, trunk, and axillae, but reach their highest development 
in the hypogastric and inguinal regions and the anal cleft, where 
they undergo papillary development. This vegetating con- 
dition, as Darier calls it, constitutes the second period of 
the disease. In Darier's case there was also a horizontal band 
of extreme confluence just above the umbilicus. In Lutz's case, 



606 DISEASES OF THE SKIN. 

at the level of the breast, was a pedunculated, flask-shaped 
growth, resting on the chest wall; it was six inches long, and 
three inches in diameter at the base and one at the summit. 
Other cases have had similar tumors, but not so large. They 
are apt to be superficially ulcerated at the follicular orifices, 
with copious discharge of highly offensive sero-pus. The de- 
nuded surface is very painful, from exposure to the air and fric- 
tion of adjacent surfaces, or of the clothing, preventing sleep 
and motion, and wearing the patient out. The tumors may also 
suppurate en masse. 

The patient also suffers from excessive sweating, and this 
produces sodden and often decaying epithelial masses which are 
inexpressibly offensive. Partly also as a result of the hyperi- 
drosis, in some cases there is considerable thickening of the 
horny layers of the palms and soles, sometimes minutely 
nodular, as on the palms of Darier's case, where there were 
small yellowish points on the papillary ridges, from thickening 
of the horny layer, evidently an inchoate stage of the diffuse 
condition. Over the knuckles and finger-joints * the horny 
layer is thickened with minutely granular whitish appearance. 
The nails are often affected, longitudinally striated or fissured, 
indented and brittle, or, according to Boeck, thickened and 
broadened even where the neighboring skin is healthy. 

Seborrhea of the scalp is common. In Thibault's case, where 
the scalp was affected the surface was covered with abundant 
dirty yellow, fatty scales, and when these were removed the 
scalp had a lobulated aspect; the nutrition of the hairs was 
unaffected, but they were united into brushlike clumps. 

In Boeck's cases the scalp was covered with warty masses 
and fatty crusts, and seborrheic eczema was present, but was 
readily cured. 

Even where there are no papular, nodular, or warty lesions 
the epidermis is thickened in its upper layers, in many regions 
of the body; on the face, the back of the hands, of the fore- 
arms, and the neck; this produces a deepening of the natural 
lines of the skin, a more or less distinct ridging, and some dis- 
coloration, from a merely dirty to a brownish hue. These 

*Fig. 4, Plate XLIV., of Author's Atlas shows these appearances; the 
nails also were striated. The case illustrated by the figure was associated 
with hyperidrosis, probably of arsenical origin. 



KERATOSIS VEGETANS. 607 

changes are seen in their greatest degree of development in 
the neck and the flexures generally, in the axillae and groins; 
the surface is marked with deep longitudinal folds of a bister 
or grayish-black color, exactly resembling keratosis nigricans. 

Itching is present in the majority of cases, usually moderate, 
but sometimes severe. The oral mucous membrane has been 
affected in several cases; thus in Fabry's, aet. sixty-seven, there 
were numerous elevations on the lips, tongue, and cheeks. 
Hallopeau also found on the inside of the lips and cheeks numer- 
ous isolated and acuminate hypertrophied mucous glands in 
the shape of nodules, from which mucus could be expressed. 
The tongue also was villous, and nodules like those on the skin 
of other parts may also be found at the commissure of the lips 
and at the external auditory meatus, blocking it in some cases 
(Schwimmer), again like keratosis nigricans. 

Etiology. — Two-thirds of the cases have been of the male sex, 
and the majority have begun before the age of sixteen. Several 
of the cases which are reported as beginning in advanced life 
are open to the suspicion of the diagnosis not being correct.* 

Three of Boeck's cases were father and two sons, and White's 
cases were father and daughter; with the former the disease 
began on the shoulder, where his knapsack rubbed it. 

Pathology. — The pathogeny of the disease as a whole we are 
unable to conjecture. But the pathological process which pro- 
duces the lesions appears to be a keratosis mainly of the mouths 
of the pilo-sebaceous follicles, as Bowen, Darier, and Lustgarten 
have shown, and also, to a minor degree, of the sweat follicles; 
the result of an anomaly in the keratinization process. Darier's 
theory of psorospermosis is abandoned even by himself, and the 
bodies he supposed to be psorosperms are acknowledged to be 
hyaline degenerated epithelial cells, but as their presence ap- 
pears to be a constant feature of the disease, they are of some 
diagnostic value. They are round cells surrounded by a refract- 
ing double-contoured thick membrane; within it is a granular 
substance with what looks like a nucleus and nucleoli. They 
contain keratohyalin, and are found at the base of the horny 

* The cases I should certainly omit are — Kronig's and Doctor's; Jarisch's 
is very doubtful. The cases in advanced life are Fahry's, Schwimmer's, 
Hallopeau's, etc., and their diagnosis is also questionable. Hallopeau's 
was remarkably like a keratosis nigricans. 



608 DISEASES OF THE SKIN. 

plugs more abundantly than in any other disease of a similar 
nature. 

Anatomy. — The anatomy has been studied by nearly all who have re- 
ported cases, but the observations of Darier, Bowen, Boeck, and Lust- 
garten may be especially mentioned; a resume is given in Unna's " His- 
opathology." The results are those given above. 

Diagnosis. — The most prominent features are the early onset 
in the majority of cases, its commencement, as a rule, on the 
face or scalp, its symmetry, its predilection for the flexures, 
neck, and mucous orifices, and the peculiar primary lesion like 
molluscum contagiosum or lichen planus at the first glance, but 
on closer inspection, instead of being pearly at the base, it is 
of a dirty red color, and crateriform when emptied of its expres- 
sible contents. There are also papules with horny covering 
compared to keratosis pilaris and sometimes wartlike. The con- 
tinuous but slow development and the vegetating offensive 
tumors of the inguino-pubic regions are diagnostic in advanced 
stages. There is a remarkable resemblance between it and kera- 
tosis nigricans, in position, symmetry, pigmentation, and 
lesions of the mouth and other mucous orifices. 

The main differences are the constant presence of Darier's 
bodies (pseudo-psorosperms) in keratosis vegetans, the onset 
being nearly always on the face or scalp, while the hands are 
less frequently affected, especially as regards the palms, and the 
mouth and tongue are less frequently involved. The primary 
lesions are different, with crusted and not such a purely horny 
covering, and although there are minute horny papules, there 
are not many like common warts. And in only one doubtful 
case (Fabry's) was there carcinoma of the stomach. 

Hyperidrosis is generally present. Minor differences are that 
it usually begins in early life, males are far more frequently 
attacked than females, and it shows a distinct family prevalence 
and apparently even heredity, unless contagion be the real ex- 
planation. 

In keratosis nigricans the primary lesions are common warts 
and papillary growths, the pigmentation is much blacker and 
more extensive, the mouth more constantly and severely 
affected; the place of onset is either the neck, back of the hands, 
or inside of thighs; the skin is dry and warty, and the thicken- 
ing, where not warty, is more extensive in area, being often 



KERATOSIS VEGETANS. 609 

correlative with the pigmentation. The scalp is very little if at 
all affected. Women are more frequently attacked than men; 
most cases begin after forty, and only four cases so far, up to 
1902, have commenced under twenty. There is no family prev- 
alence, and in a very large proportion of adult cases there has 
been very serious visceral disease. 

The difficulty is that, except the character of the primary 
lesions and the Darier bodies, none of these differences are 
constant. 

But while there are many resemblances of keratosis vegetans 
to keratosis nigricans, the relations between the former and 
keratosis follicularis contagiosa of Brooke are still closer. 

The main differences are the absence of psorospermlike 
bodies in Brooke's case, no papillomatous growths and no 
greasiness, or offensive odor, and the lesions are easily curable 
but very liable to return. All these discrepancies might be due 
to Brooke's cases being an early stage of keratosis vegetans. 
Brooke's disease is evidently contagious, while K. vegetans is 
said to show a family prevalence and heredity. This heredity 
may only be apparent, and contagion from parent to child the 
real explanation. 

The resemblances of the two diseases are — both begin in 
early life as a rule. In both there is diffuse thickening of the 
epidermis, so that the natural lines of the skin are deepened; 
both have spiny growths, which when forcibly removed leave 
the orifices in the follicles patulous. The head and neck is a 
favorite place of attack; and finally, the same cases have been 
claimed for both diseases. 

Prognosis. — Xo case has yet been reported as cured or even 
materially benefited by treatment; it is slowly progressive, with 
tendency to aggravation rather than amelioration, but without 
much injury to health as a rule. 

Treatment. — Nothing hitherto devised has exercised more 
than a temporary amelioration of the condition except as regards 
the scalp, where improvement ensues under the same treatment 
as that for seborrheic eczema, to which the reader is referred. 
Bowen found an ointment of sulphur, salicylic acid, and daily 
washing produced marked improvement. Offensive secretions 
from the axillae and groins could be controlled by antiseptics 
of the iodoform class, such as europhen or loretin, or formalin 
39 



610 DISEASES OF THE SKIN. 

three per cent, in starch powder, sulphur baths, etc. The effect 
of thyroid in ichthyosis suggests that it might be useful in this 
disease, five grains of the extract or one grain of the colloid 
being given once a day to commence with, and the dose in- 
creased as the patient became accustomed to it. I am not aware 
that it has been tried. 

Keratosis Follicularis Contagiosa (Brooke). — Brooke* claims 
as previous examples of the very rare disease he describes, 
the acne sebacee cornee (Cazenave), acne cornee (Leloir and 
Vidal), and ichthyosis sebacea cornea (Wilson), already as- 
signed to keratosis vegetans; ichthyosis follicularis (Lesser), 
and Morrow's f keratosis follicularis. 

While there is much ground for believing that Brooke's follic- 
ular keratosis is a mere variant or an early stage of keratosis 
vegetans, it is provisionally described separately until the con- 
necting links are more certainly identified. Clinically, also, the 
disease has resemblances to lichen spinulosus, but the latter is 
not contagious, and does not show family prevalence. 

The disease occurs most frequently in children, among whom 
it spreads by contagion, and sporadically it is seen in adults. 

It is symmetrical in distribution, attacking chiefly the neck, 
especially the nape, the shoulders, and extensor aspect of the 
limbs; the trunk to a less degree, the face, buttocks, and flexor 
aspect of the limbs. In most cases it spreads slowly and con- 
tinuously from above down. 

In Brooke's type case it began on the nape, as little black 
spots, which developed into papules giving a dirty yellow and 
eventually brown hue to the affected area. The black specks 
projected, and comedo-plugs and small spinelike growths were 
produced. 

The first change was a thickening of the horny layer, so that 
the natural rhomboids of the skin were accentuated. In each 
of these minute black specks appeared, generally in threes, but 
only one developed a papule, and on this a spine formed on 
the top, and some of them became slightly inflamed. Some- 

* Brooke, " International Atlas of Skin Diseases," Fascic. vii., Plate 
XXII. 

f Morrow, "Keratosis Follicularis," Jour, of Cut. &z's.,vol. iv. (1886), 
p. 257. 



KERATOSIS VEGETANS. 611 

times the spines were long and thin, like bristles, at others 
short, thick, comedo-like plugs, but they were always firmly 
rooted, and left a gaping follicle when extracted, the surface 
being as rough as a nutmeg-grater, 

The larger papules were fleshy, and often inflamed like acne 
vulgaris pustules, while others resembled acuminate warts. In 
parts they were agglomerated into rough, lumpy patches, and 
the papules and surrounding skin had a dirty yellowish-brown 
hue. The disease was most highly developed on the outer 
surface of the posterior fold of the axillae, where the agglom- 
erated papules looked like a mass of small warts, from the top 
of which projected curved horny plugs two or three inches in 
length. 

Out of seven children six became affected, evidently from 
contagion, and in another family three children were attacked. 
Brooke had two other cases also girls, set. thirteen and six 
years. Graham Little * has shown two cases in one family (a 
third was affected) to the Dermatological Society. Barbe f 
has had two boys, set. seven and a half and eight and a half 
respectively; and Elliot J of New York a Russian boy, set. 
fourteen. 

Pathology. — The lesions have been examined by Vidal and 
Leloir, Robinson in Morrow's case, and Brooke agrees with 
their observations. 

The process is a hyperkeratosis, affecting chiefly, but not 
exclusively, the pilo-sebaceous follicles, the sweat pore spirals, 
and the deep and superficial furrows. 

The hyperplasia extends to the other epithelial layers, espe- 
cially to the stratum granulosum. Some irritant not yet deter- 
mined apparently starts the process, and the contagious char- 
acter of the disease points to its being a living organism, but it 
has not been yet discovered. Neither Brooke, Wickham, nor 
Unna could find psorospermlike bodies in Brooke's case, and 
in this respect it is unlike White's, Darier's, and other cases of 
keratosis vegetans, in which they were constantly found. Brooke 
also considers that clinically it differs from keratosis vegetans 

* Brit. Jour. Derm., vol. xiii. (iqoi), p. 417. 

f Annates de Derm, et de Syph., vol. ii. (iqoi), p. 535; also p. 422, case 
by Baudoin and du Castel, a male, set twenty. 

% Elliot, Jour. Cut. and Gen.-Ur. Dz's., vol. xii. (1894), p. 362 



612 DISEASES OF THE SKIN. 

in the absence of papillomatous growth and the freedom from 
greasiness of the skin and offensive odor, the skin being really 
dry and harsh. See the diagnosis of keratosis vegetans for 
further details, and the criticism of the differences. 

Brooke cured his cases by inunctions of iodid of mercury in 
mollin (lard saponified with caustic potash, to which some fresh 
lard and a little glycerin is added). In both Barbe's cases, 
there being evidence of congenital syphilis, he gave them 
mercury and iodid of potassium, and the lesions disappeared, 
though they returned in a week, when the treatment was 
stopped. 

ANGIOKERATOMA. 

Deriv. — dyyeiov, a vessel; uepaS, horn. 

Synonyms. — Lymphangiectasis (Colcott Fox); Telangiectic 
warts (Dubreuilh); Lichen telangiectasique; Telangiectasie 
verruqueuse (Brocq). 

Definition. — A disease of the extremities characterized by 
warty-looking growths, which develop on dilated vessels, in 
persons with a chilblain circulation. 

This is a very rare and not very important disease, but with 
definite clinical characters. The first published case was by 
Wyndham Cottle.* A case of my own was alluded to under 
Verruca in the first edition of this work (1888), and cases have 
since been described in detail by Colcott Fox, Mibelli, Du- 
breuilh, Pringle,f Fordyce,^ etc. Mibelli's name is the one 
which has gained acceptance. 

All the patients were, or had been, the subjects of chilblains, 
and dark spots the size of pin's points to pin r s heads, evidently 

*St. George's Hospital Reports, vol. ix. for 1877-78, 758, with colored 
illustrations. 

\ Pringle has given a very complete resume of the disease with good 
colored illustrations and bibliography (except Cottle's case) to date, in 
Brit. Jour. Derm., vol. iii. (T891), p. 237, August, September, and 
October numbers. My own case was given in the November number. 

\ Fordyce, Amer. Jour. Cut. Dis., vol xiv. (1896). Colored illustration 
of scrotum affected, and references Cases are now getting too numerous 
for separate mention. Joseph reported 6 cases from Berlin, Audry 34, 
and Escaud 25 cases from Toulouse; Tommasoli 21. 



A XGIOKERA TOM A . 613 

vascular, developed as an attack of chilblains was subsiding. 
These venous dilatations persisted for an indefinite time, ana 
new ones formed winter after winter, with and without fresh 
chilblains. They were discrete at first, but most of them were 
irregularly grouped, and ultimately blended into a small patch 
from one-eighth to one-third of an inch in diameter, which be- 
came distinctly elevated above the surface into a small convex 
mass, and at the same time horny points developed amongst 
the vascular dilatations, giving the appearance of warts with 
venous vascularity at and round the base, and telangiectic warts 
they were supposed to be, by myself and others, until their de- 
velopment was traced, in other cases, from venous points, and 
the cornification was shown to be a secondary feature. None 
of these lesions show the slightest tendency to spontaneous 
involution, but the larger ones persist with very little change, 
and fresh vascular points form each winter and develop into the 
warty stage, or go to increase the size of adjacent warty lesions. 
These lesions occur on the fingers and toes, and on the parts 
of the hands or feet immediately adjacent, never extending much 
beyond the knuckles or roots of the toes. In Sangsters case 
the ears were affected. The palmar or plantar surface may be 
involved, but only to a comparatively trifling extent as a rule, 
but in Saint-Philippe's case they were abundant on the palm, 
nearly all the lesions being on the dorsal surface of the pha- 
langes; and in a well-marked case all the stages of development 
may be seen at once. There are no subjective symptoms, but 
the larger ones bleed easily, and they are always worse in cold 
weather. 

Variations. — Further experience has shown that the vascular 
lesions are not limited to the extremities of the circulation, and 
are not, therefore, always in etiological relationship to chilblains. 

Thus Zeissler's case, in addition to typical lesions on the 
hands and feet, presented nevus-like patches and pedunculated 
vascular tumors on the forearms, legs, thighs, and ears. In 
Fordyce's case the scrotum only was affected, chiefly at the back 
and sides, the lesions being in lines following the folds of the 
scrotum. In W. Anderson's case,* a man set. thirty-nine, the 
vascular points and growths had been developing from the age 
of eleven to twenty-two, and had since been unaltered. They 
* Brit. Jour, of Dermat., vol. x. (1898), p. 113. 



6 1 4 DISEASES OF THE SKIN, 

affected the whole surface, except the face, palms, and soles, 
in innumerable puncta and papules of a purplish-red color, from 
a point to a hemp seed in size, most developed on the scrotum 
and inner side of the left thigh. 

In all these cases the verrucose element was nearly or en- 
tirely absent. As associated conditions it may be mentioned 
that Zeissler's and Fordyce's cases had leukodermia, and in 
Anderson's and Dubreuilh's cases there was congenital deform- 
ity of the fingers. All of them were males. 

Etiology. — In cases limited to the extremities all the patients 
have been young, and the disease has dated from childhood. 
Most of them have been of the female sex, and all have been 
subject to chilblains, the lesions having always started immedi- 
ately after an attack, and been aggravated each winter. Some 
cases have been associated with Raynaud's disease. In the 
trunk cases the facts are too few for generalization, but so far 
they have been of the male sex and chilblain circulation has not 
been an etiological factor. 

Pathology. — As a result of repeated chilblain inflammation, 
capillary vessels become dilated in the papillae, followed by 
chronic inflammatory changes in the papillary layer, and over- 
growth of the epidermic layers above them, when the disease 
is in the extremities, but when in the scrotum and trunk, most 
if not all of the secondary changes are absent. 

Anatomy.— This has been investigated by Colcott Fox, Mibelli, Pringle, 
and others.* The observations of the last two agree in the main. 

There was great thickening of the stratum corneum, stratum lucidum, 
and rete mucosum, the last chiefly at the margin of the diseased area, 
and in this layer were large irregular lacunae, some still with blood in 
them. 

In the upper part of the papillary layer were copious leukocyte infil- 
tration, increase of the fibrous tissue, and general dilatation of the blood- 
vessels. The subpapillary layer was only slightly affected in Pringle's 
case, but more so in Mibelli's; the latter's showed less leukocyte infiltra- 
tion and he thought there were dilated lymph spaces. 

W. Anderson found in his trunk case varicose dilatation of the papil- 
lary blood-vessels, thinning or absence of the rete layer above them, 
while the horny layer was unchanged or thinned. Thrombi were present 
in many of the vessels. Fordyce found some hypertrophic changes in 
the horny and prickle cell layers as well as the vascular changes. 

* Wisniewski gives good colored plates of microscopic appearances, 
Archiv f. Derm. u. Syfih., vol. xlv. 



SCLER0DERM1A. 615 

Diagnosis. — The occurrence of warty-looking growths with a 
purple vascular base, and accompanied by purple dots on the 
extremities and ears of a person with the chilblain circulation, 
is absolutely diagnostic. The mode of development of the 
warty lesions from the aggregated vascular points would dis- 
tinguish them from true warts. In the trunk case only the 
venous dilatations might be present. 

Treatment. — The most effectual treatment appears to be that 
successfully employed by Pringle, viz., electrolysis of each 
lesion, into which a needle attached to the negative pole is 
introduced, with a current of three milliamperes, until coagula- 
tion of the blood in the vessels is produced. To prevent the 
formation of fresh lesions in the winter, general invigorative 
measures should be adopted, and the patients encouraged to 
take as much active exercise as their circumstances permit. 

SCLERODERMA. 

Deriv. — GuXtfpo?, hard; and Sippia 9 the skin. 

Synonyms. — Scleroderma; Hide-bound disease; Sclerema or 
Scleroma adultorum; Scleriasis; Dermato-sclerosis; Chori- 
onitis; Sclerostenosis; Fr., Sclereme des adultes, Sclero- 
dermic; Her., Hautsclerem. 

Definition, — A subacute or chronic disease characterized by 
extreme induration and rigidity of the skin. 

The first case known is that of a Dr. Curcio of Naples in 
1752.* A few isolated cases were subsequently recorded by 
Lorry, Henke, Alibert, etc., but it was not until Thirial's paper 
in 1842, recording two cases under the name of " Sclereme des 
adultes," that the attention of the profession was attracted and 
the disease generally recognized. 

There are three classes of cases: 

1. Where the skin affection is diffuse and symmetrical. 

2. Where it is circumscribed, usually called morphea. 

3. Mixed cases, where there is a combination of the two 
forms. 

Although they all have the same anatomical basis, the first 

* Quoted by Willan, p. 208, under the name of ichthyosis cornea, Col- 
cott Fox, " Note on the History of Sclerodermia in England," Brit. Jour 
Derm,, vol. iv. (1892), p. 101, gives references to many of the old cases. 



616 DISEASES OF THE SKIN. 

two differ clinically and etiologically in many important points, 
and are therefore described separately. 

DIFFUSE SYMMETRICAL SCLERODERMA.* 

This is a very rare disease, but owing to its striking peculiari- 
ties, many cases are on record. I have had seven females and 
five males under my own care, and have examined many more. 

This form presents itself under two phases: infiltration, or, as 
it is more commonly but incorrectly called, hypertrophy, and 
atrophy, clinically represented by swelling and then shrinking of 
the skin. The infiltrated form is the early stage, and may be 
hard from the first or edematous; the shrunken is a sequel of 
the swollen stage, which has then generally been edematous in 
the first instance. The disease frequently comes on after ex- 
posure to cold or wet, often with pains in the joints, or there 
may be no symptoms before the stiffness of the skin sets in. 
This may spread in a few days over a large part, or even the 
whole of the body surface, or again, the disease may be so 
insidious and gradually progressive that the patient can scarcely 
mark its commencement, and it is progressive for many years. 
There is no elevation of temperature, unless from complica- 
tions, and there is often very little or no disturbance of the gen- 
eral health. The commonest positions for the stiffness to be 
first felt are the back of the neck, the chest, shoulders, and arms; 
at all events, in some part of the upper half of the body with few 
exceptions, f This stiffness increases in intensity and extent 
either slowly or rapidly, traversing a great part of the trunk, 
limited below by a horizontal line, of which the edge is imper- 
ceptible to the eye, and to the touch is ill-defined, merging 
gradually into the healthy skin. Sometimes there is a zone of 
dilated vessels marking the boundary of the healthy and un- 
healthy skin. The scalp, face, neck, and upper limbs may all 
become involved, each joint being fixed as the skin over it be- 
comes rigid. In the hard cases the volume of the part affected 

* " Lectures on Sclerodermia," by the author, Lancet, vol. i. (1885), pp. 
191, 237, 927, 975. 

f Finlay's case began in the feet and legs arid spread upwards, Brit. 
Jour. Derm., vol. i., August, 1889. In a case of Ewart's with a mild 
form of Raynaud's disease, it was centripetal, beginning in the hands, 
feet, and face. 



DIFFUSE SYMMETRICAL SCLERODERMIA. 617 

is increased, and the infiltration of the skin makes it extremely 
tense. The muscles * may be implicated, resembling rigor 
mortis, and the whole skin is so hard that it suggests the idea 
of a frozen corpse without the coldness, the temperature not 
being more than a degree or two below the normal. No pitting 
can be produced by pressure, and all attempts to pinch it up are 
futile; but when the finger is drawn across with firm pressure, it 
makes a white streak with pink borders, and the normal color 
is only slowly regained. 

When the face is affected it is Gorgonized, so to speak, both 
to the eye and to the touch. The mouth cannot be opened; the 
lids usually escape, but if involved, they are either half closed, 
or when contraction takes place, drawn widely open, but im- 
movable in either case. The effect of the disease on the chest 
walls is to seriously interfere with respiration and flatten and 
almost obliterate the breasts, and upon the limbs, to fix the 
joints in a more or less flexed position from the shortening of 
the distended skin. 

In some instances the mucous membrane of one or the other 
of the cavities is affected, including that of the mouth, tongue, 
palate, pharynx, esophagus (judging from occasional dys- 
phagia), larynx, and vagina. In short, no part of the body sur- 
face is exempt, though the palms and soles are perhaps the most 
rarely involved, escaping sometimes when the whole of the rest 
of the body is affected. While the disease displays a decided 
preference for the upper portion of the body, it is most erratic 
both in what it includes and in what it passes over, but is always 
symmetrical in distribution, though not in intensity, and the 
legs are never affected without the arms, though the contrary 
is often noticed. The surface of the skin may be very little 
altered to a casual observer, but closer inspection shows that 
the natural lines are obliterated. There may be some patchy 
erythema at first, and later, minute vessels are dilated and form 
telangiectasic tufts and strise, contrasting with the rest of the 
surface, which is paler than normal as a whole, and in parts is 
quite white from the obstruction of the circulation, of which 
many of the symptoms are a consequence. Pigmentation is 

*The muscles may be affected independently of the skin, though 
usually the skin and other tissues are simultaneously involved. Cases 
are recorded by Goldschmidt, Westphal, Mery, Thibierge, etc. 



618 DISEASES OF THE SKIN. 

often present, striated, mottled, or diffused over a large area, 
and varying from a pale fawn up to a deep brown or almost 
black. 

Subcutaneous tubercles have been observed in a few cases 
(Hutchinson, Gaskoin, Tresidder, and myself *) ; they appear to 
me to be of the same nature as " rheumatic nodules," occur 
especially over bones, and disappear spontaneously; and it is 
probable that they would be often found if specially looked for. 
According to Mery and Brissaud there is sclerosis of the viscera 
and all soft parts in some cases; but, except as regards the mus- 
cles and myocardium (Mery), I am not aware of any anatomical 
proof. The hair falls off in some cases, but not permanently, 
and the nails may also be involved. 

Sensibility is rarely affected, but both increase and decrease 
have been noted. In a case which came under my notice very 
severe apparently neuritic pains occurred at intervals, preceding 
attacks of acute dermatitis, but not limited to the affected skin. 
There was also great tenderness of the surface. Pruritus is 
more frequent, and in one of my cases was a very troublesome 
symptom. 

The secretion, both of sweat and sebum, is diminished in pro- 
portion to the intensity of the affection, and may be quite 
absent, so that the skin gets rough and peels, and on the legs 
may be almost ichthyotic from the dryness of the cuticle; in 
the atrophic form the palms and soles, however, are generally 
moist. 

Edematous form. — In this set of cases edema instead of indura- 
tion is first observed, not, however, of the usual doughy kind, 
but a stiff edema, resembling, as Wilson puts it, the pitting 
produced by pressing the finger into a bladder of lard. After 
this has lasted a variable period, amounting to some weeks or 
months, the edema becomes absorbed, the skin begins to shrink, 
acquires a dried or ivory-white color, and the atrophic stage is 
reached. This is the course of most of the edematous cases, 
and I believe of all of them, while it is very doubtful if the cases 
which are primarily hard and infiltrated ever become atrophic, but 
this requires further observation. 

*Jane E., set. thirty-nine (U. C. H., females), and Tresidder, Lancet, 
June i, 1895, p. 1378. In Eichoff's case the nails were brittle, and there 
was a horny mass between the nail and its bed, Archiv f. Derm. u. 
Syph. y Heft 6, i8qo. 



DIFFUSE SYMMETRICAL SCLERODERMIA. 619 

The atrophic condition is not so widely spread as the edema 
which preceded it, and is more frequently confined to the face 
and the limbs, especially the upper, but the symmetry is re- 
tained, and the alteration is much more obvious to the eye. In 
the face the skin, from pressure-atrophy of the fat and muscles, 
is stretched over the bones to which it may be directly adherent, 
the lips are shortened, the gums shrink from the teeth and lead 
,to their falling out, and the nostrils are compressed. As in the 
other form the lids generally escape, but the hard edge of the 
lid has been known to produce ulceration of the cornea, or their 
contractions may keep the eyes permanently open. The 
stretched skin, the emotionless features, with the pallor relieved 
only by telangiectasic striae, give the countenance a ghastly, 
corpselike aspect. 

The same process affecting the limbs — the arm, for exam- 
ple — reduces the limb of an adult to the size of a child's, anky- 
loses the joints, and distorts the hand, so that the third and 
fourth fingers are curled up into the hand, the first and second 
are bent at the first phalangeal joint, while the thumb pha- 
langes are overextended; this is called "sclerodactylia."* 
The limb looks and feels like an ivory carving; the skin is even 
more unyielding than in the infiltrated form, but from shrinking, 
not distention. In consequence of the tension of the skin over 
the joints, ulcerations easily ensue upon slight injuries, and 
necrosis of the phalanges f may result, sometimes with great 
pain. In a case recorded by Leredde and Thomas there were 
multiple and very painful erosions and ulcerations of the affected 
skin. When the tendon of the biceps is involved it forms a 
tight cord across the front of the forearm and flexes the limb 
at a more or less obtuse angle. On the other hand, in one of 
my cases J it missed out a piece of skin at the flexure of the 
elbow and knee, olecranon and patella, on each side, and left 

* Sclerodactylia begins in some cases at the finger-tips and extends up- 
ward very gradually, and more often is part of general sclerodermia. It 
may develop in association with Raynaud's disease without other symp- 
toms of sclerodermia. 

f Zambaco and Berillon relate such a case, and Zambaco not only com- 
pares it with mutilating leprosy, but actually regards the case as marking 
a transition from sclerodermia to leprosy. Annates de Derm., etc., vol 
iv. (1803), p. 753. 

% Jane E., aet. thirty-nine (U. C. H., females). 



620 



DISEASES OF THE SKIN. 



comparatively free movement in those joints, while those below 
them were fixed. Owing to the ivory-white color and to the 
shrunken parts being below the healthy skin, the end of the 
diseased surface is easily seen; but the disease may affect the 
deeper tissues, somewhat beyond the visible border, which is 
irregular, and may be fringed with a pink or violet zone of small 
dilated vessels. Pigmentation affects these cases more fre- 
quently and intensely than in the infiltrated form. 

The course taken by the two forms differs somewhat. The 
tensely infiltrated cases tend to clear up, sooner or later. Im- 



- ■ 'fv" .: HH 


B 'rU 


1l~ ' 




1 HH ^ 

■ 

1 

1 


A 

B 



Fig. 30. — From a case of Sclerodactylia which I treated with Dr. Dercum 
of Philadelphia, to whom I am indebted for the radiogram, which 
shows that the joints are unaffected while the soft tissues have shrunk. 

provement sets in gradually; the infiltration is slowly absorbed; 
the skin becomes gradually softer, and after some months, or 
even years, regains its normal elasticity. Whether any of these 
cases degenerate into the atrophic form is not quite settled. 

Progress towards recovery is not, however, uninterrupted. 
A slight chill (and the patient is very sensitive to cold) may 
aggravate the disease, and even extend the process, and the 
patient, from internal causes also, may feel his skin tighter on 
some days than others. In the contracted form recovery is less 
frequent; the disease often remains stationary for years, and in 



DIFFUSE SYMMETRICAL SCLERODERMIA. 621 

rare cases fresh portions of the body may from time to time 
be affected, and the patient may sink under it with emaciation 
and exhaustion. Improvement may eventually set in, if judi- 
ciously treated, and the induration may entirely disappear; but 
nothing can restore the atrophied tissues, and some of the 
joints having become permanently ankylosed, more or less de- 
formity is left. The ankylosis is, however, never bony, but 
entirely due to the fibrous contraction. This was well shown 
in the section of a finger of a patient of mine who died from 
heart disease, and in whom the disease, in the atrophic form, 
had been present twelve years; the induration, however, having 
quite cleared up for some years before death, leaving only the 
deformities and thinned skin. If the disease last long emacia- 
tion sets in, and the whole vital powers appear to be dimin- 
ished, so that the patient more easily succumbs to other diseases 
to which he may be exposed. 

Complications. — Acute rheumatism is the most common com- 
plaint which may precede or accompany the sclerodermia, and 
cardiac valvular disease may be present, either with or without 
the joint manifestations of rheumatism. Myositis with pain and 
contractures of the limbs have been repeatedly observed; in 
Kaposi's case * nearly all the muscles of the trunk and limbs 
were invaded, and the sclerodermia spread over the whole body, 
with great emaciation from the constant pain. Peripheral neu- 
ritis may occur. Enlarged thyroid with or without exoph- 
thalmic goiter may coexist, as in the cases of Jeanselme, Booth, 
Leube, and Kahler, but atrophy of the thyroid, often unilateral, 
with fibroid changes, is more frequent. In Hektoen's case the 
thyroid weighed only fourteen grams instead of twenty-two. 
Necrosis of the phalanges has already been mentioned, and Ull- 
mann showed a case with necrosis of the bones on each side 
of the face. Muscular atrophy f apart from sclerosis is not 
infrequent, and syringo-myelia J in a few instances, with the 

♦Kaposi, Annates de Derm., etc., vol. ii. (i8gr), p. 881. 

\ Dreschfeld, Med. Ckron., Manchester, January, 1897, p. 263. Two 
cases, one with progressive muscular atrophy, the other with trophic 
ulcers. Schultz of Brunswick found extensive lesions of the anterior 
roots of the spinal cord. 

\ Mendel met with a case of a woman, set. forty-one, in whom after suffer- 
ing from Raynaud's disease to the extent of coldness andlividity for two 
years, symptoms of Morvan's disease appeared, followed by atrophic 



622 DISEASES OF THE SKIN. 

respective lesions in the anterior cornua, and gliomatosis have 
been found. 

Of associated skin lesions Raynaud's disease is the most com- 
mon, and may precede or accompany it; many have had syn- 
copal attacks affecting the fingers for years before the sclero- 
dermia. Sclerodactylia may follow Raynaud's disease without 
other symptoms of sclerodermia. Other vaso-motor disturb- 
ances, such as transitory swellings, throbbing in the epigas- 
trium, and frequent vomiting, occurred in one of my cases. In 
another eczema capitis was present in the height of the sclero- 
dermia, but yielded to the usual treatment; acne and urticaria 
also occur, and especially the factitious form, which is char- 
acterized by its slow development and unusually long duration. 
In a case under Bettmann * with commencing sclerodermia, on 
the chest and back, where the sclerodermia had not yet ap- 
peared, the factitious urticaria took several minutes to develop, 
and lasted for five or six days without change. Lupus erythe- 
matosus preceding the sclerodermia has been observed by 
Cavafy, Pringle, and Brissaud, and by Hallopeau developing in 
a sclerodermic patient. 

Children. — Although the name adnltorum has been appended 
in contradistinction to sclerema infantum, with which it has no 
connection, sclerodermia frequently occurs in children, and 
bears the same character among them, except that it tends to 
run a more acute course both in onset and termination, while 
the atrophic phase is less often developed. In a child of twelve 
who came under my care through the kindness of my colleague, 
Dr. Eustace Smith, the whole body surface was involved, except 
the palms and soles, within a fortnight, and there were endo- 
and peri-carditis ; yet within three weeks some diminution of the 
induration set in, though it was twelve months before she was 
quite well. Many run a much slower course than this. 

Etiology. — Women are much more prone to this disease than 

sclerodermia, with marked bronzing of the face. Deutche. med. Woch. 
No. 34. 1891. Abs. Brit. Jour. Derm., vol. iii. (1891), p. 94. Other cases 
are Herrinsfbam's case, Clin. Soc, Brit. Med. Jour. November 4, 1899, p. 
1290; Tresidder, Lancet, June 1, 1895, p. 378; Clin. Jour., May 8, 1893, p. 
313; S. Mackenzie, Henton White, Lancet, April 25, 1896, p. 1136; Ewart, 
Harveian Society, Lancet, February 15. 1902, p. 450. 

* Berlin klin. Wochensch., April 8, 1901. Abs. Brit. Med. Jour., 
Epitome, April 27, 1901. 



DIFFUSE SYMMETRICAL SCLERODERMIA. 623 

men, in the proportion of three to one, and young and middle- 
aged adults are the most frequent victims ; but thirteen months * 
and seventy years \ are the extremes of age on record. 

Among other predisposing causes previous attacks of Ray- 
naud's disease and acute rheumatism and erysipelas play the 
most important part, probably from such subjects being unduly 
sensitive to cold; privation and exhausting emotional condi- 
tions are also said to be the causes. Chills, especially after hav- 
ing got the clothes drenched, have been the exciting cause of 
many cases. In one case (Pick) % it followed directly after 
exposure to the sun on a long march. Most instances from 
these causes are comparatively acute. Many patients have had 
previous good health up to the time of the sclerodermia, and 
no cause could be assigned for it, and the slow, insidious cases 
generally baffle investigation as to their origin. Bancroft's § 
observations of the concurrence of filaria sanguinis with 
sclerodermia are probably only coincidences. Touton records a 
case, the result of injury from a splinter of wood. In Abra- 
ham's case a fall on the back immediately preceded the onset, 
Brissaud quotes a case after an injury to the skull, and other 
cases make it probable that injuries may be exciting causes. 

Dana thinks all infectious conditions may give rise to sclero- 
dermia, and the fact that cases have occurred in connection 
with tuberculosis (Besnier and Ehlers), erysipelas (Chaufford 
and Schaper), diphtheria (Marsh), scarlet fever (Pringle), lends 
some support to this view. 

In a case in EichhofFs clinic there were ulcers round the nails 

* Isambert, Gaz. Hebd., 1863, p. 840; Faivre, Annates de Derm., vol. ix. 
(1898), p. 179; and Norman Moore, St. Bart.'s Hospital Reports, vol. ix. 
p. 70, records a case of two years. Grasset in the Iconographie de la 
Salpetriere, No. 5, 1896, describes a case of a youth of eighteen in which 
an atrophic sclerodermia began at two years of age, progressed up to 
twelve years, and had since remained stationary. The physical develop- 
ment had been quite stopped, while the brain and rest of the nervous 
system were intact. He was only 4 ft. 6 in. high, weighed fifty-three 
lbs., and was like a skeleton with the skin stretched tightly over it. 

fDr. Fletcher's case, Clin. Jour., March 31, 1897. Another case of 
seventy-two was that of a man in whom the disease affected both legs 
(Dr. Sidney Roberts, Sheffield Med. Chir. Soc). Jane R. (U. C. H.) was 
sixty-seven years. 

% Viertelj.f. Derm. u. Sypk., 1884, Heft i., p. 227. 

§ Lancet, February 28, 1885, p. 380. 



624 DISEASES OF THE SKIN. 

from favus, and from these sclerodermia started and gradually 
spread over the whole body surface. The favus was cured with 
pyrogallic acid and the sclerodermia retroceded. 

Pathology. — Of this we know very little. Most of the symp- 
toms are referable to obstruction, on the one hand, to the 
arterial blood supply, and, on the other, to the venous and 
lymph flow. 

The symptoms, which differ so much in many cases, mainly 
depend, in my opinion, upon the varying degree in which the 
obstruction affects one or other of these vascular systems. 

The disease is not one of lymph obstruction alone, or we 
should get the condition of elephantiasis arabum, as Kaposi 
points out, but there can be little doubt that it plays an im- 
portant part; and if the arterial supply were diminished, there 
would not be the excessive hyperplasia which is seen in ele- 
phantiasis. The obstruction is apparently, in great part, due to 
the cell effusion, which forms a sort of sheath round the vessels, 
apparently an endo- and peri-arteritis, but what the original 
defect is which starts this is obscure. The sclerosis is the out- 
come of the endarteritis. The most plausible and generally 
received theory is that of a defect in the nervous system, high 
up necessarily, since the disease affects the face, and not im- 
probably in the vaso-motor center, but how this nerve influence 
produces these special phenomena cannot be explained satis- 
factorily. 

Brissaud,* after discussing all the theories put forward, con- 
cludes that a primordial disturbance of the great sympathetic 
originates the disease. 

Mott was unable to find any lesions in the central nervous 
system. Leredde and Thomas regard the dermato-sclerosis 
and accompanying arteritis as probably due to a toxin. The 
co-existing changes in the thyroid found in some cases have led 
to that being supposed to be the fons et origo mali, as in 
myxedema, but against this is the fact that, while atrophy is 
most common, hypertrophy of the thyroid also occurs. 

Anatomy. — The skin of diffuse sclerodermia has been examined anatom- 
ically by Forster, Neumann, Kaposi, Schwimmer, Babes, Chiari, Fagge, 

*" Pathogenesis of Sclerodermia," La Presse Medicate, No. 51 (1897, 
p. 285. Full Abs. in Brit. Jour. Derm., vol. ix. (1897), p. 367, with many 
valuable references. 



DIFFUSE SYMMETRICAL SCLERODERMIA. 625 

Unna, and others, the skin having been taken from both the living and 
dead subject, and though differing in some particulars, probably from the 
disease not having been in the same stage in all, the results agree in the 
main, and may be stated as follows : 

The changes are almost entirely in the corium and subjacent tissues, 
pigmentation of the rete, as well as the corium sometimes, being the 
only epidermic change as a rule, though Neumann found downgrowth in 
one case. The vessels are narrowed by the pressure of layers of cells of 
varying thickness which surround the vessels like a sheath (Rasmussen, 
Kaposi, etc.), and in Schwimmer's case, examined by Babes, there was 
narrowing from concentric hypertrophy of the media and intima. What 
leads to this accumulation of cells is not known, and it cannot be shown 
whether they are derived from the lymph channels round the vessels or 
are emigrant cells from the blood-vessels, but they do not appear to be 
of inflammatory origin, as all other evidence of inflammation is wanting. 
Masses of cells are especially abundant round the sweat and sebaceous 
glands, the hair follicles, and in the panniculus adiposus. These tend by 
their pressure to produce atrophy of the subcutaneous cellular tissue, but 
they are never seen in the papillary layer (Neumann). 

The blood-vessels also, while well filled with blood and broad at the 
lower part of the corium, are bloodless near the papillae, and are also here 
thin-walled and diminished in number. 

These changes in and around the vessels are probably the primary and 
leading feature, to which the other anatomical lesions are secondary. 
These latter are increase of the connective and elastic tissues of the 
corium, the meshes of which are closer together than usual, and hyper- 
trophy of the organic muscular fibers. There is ectasia of the sweat 
glands, the cell masses are abundant round them, and eventually pro- 
duce destruction of the acini and of the hair follicles, and atrophy of the 
fat and subcutaneous cellular tissue from the pressure of the cell prolifer- 
ation; and nothing else intervening, the condensed overgrowth of the 
connective tissue of the corium may be directly adherent to the fascia or 
periosteum. This description of the secondary changes applies to the 
later stage of the disease. 

A. Mott was unable to find any lesions in the central nervous system, 
in the peripheral nerves, or in the posterior root-ganglia in a case of 
Galloway's which had suffered from sclerodermia for years. 

Unna* examined a case of three months' standing when the disease 
was at its height, and states that " the main process is a hypertrophy of 
the pre-existing collagenous bundles all through the cutis, which leads 
to simple pressure atrophy of the vessels as well as of the epidermis 
structures." 

Diagnosis. — The wooden induration and immobility of the 

skin and subcutaneous tissues, occurring symmetrically over a 

wide area, with or without the ivory color supervening, and 

the surface otherwise so little altered, are conditions peculiar 

*"Histopathology," p. 1110. 

40 



626 DISEASES OF THE SKIN. 

to sclerodermia, with the sole exception of sclerema of the new- 
born, in which there is induration with great coldness of the 
surface. This, and the age of the patient, would be obvious dis- 
tinctions, thirteen months being the youngest age of any re- 
corded case of sclerodermia, so that there can really be no 
difficulty in diagnosis from the affection of the new-born. In 
slighter degrees of development the difficulty of pinching up the 
skin being greater than the infiltration would account for is 
characteristic. For the diagnosis from the rare disease xero- 
dermia pigmentosa see that disease, while most of those excep- 
tional cases of so-called general atrophy of the skin are really, 
in my opinion, examples of atrophic sclerodermia (see Atrophia 
cutis). There remains only one disease, even rarer than sclero- 
dermia, which may give rise to some doubt, namely, diffuse pri- 
mary or secondary cancer of the skin — " cancer en cuirasse " of 
Velpeau. If secondary, it often begins as nodules; this and the 
previous history would remove all doubt. But in the primary 
cases it may be difficult; the slow, continuous spreading, the 
lancinating pains and tenderness, the neighboring inflammatory 
edema, the ulceration of the lesions, and involvement of the 
glands, with the more rapid course to marasmus and fatal 
cachexia, are all points in which it differs from sclerodermia,. 
and would guide to the correct diagnosis. 

Prognosis. — Speaking generally, the disease, as a rule, tends 
to get well spontaneously, but it is impossible to predict how 
long any case may take; rarely less than twelve months is 
required for complete recovery, though improvement may begin 
in a few weeks; on the other hand, the hardness may last sev- 
eral years, with exacerbations and remissions. The swollen are 
much more favorable than the shrunken cases, and, in my 
opinion, those which are indurated from the first are more 
favorable than those which are edematous, as they are less likely 
to become atrophic. As long as there is induration with dis- 
tention, hopes of complete recovery may be entertained; when 
atrophy has set in, although, either as a result of treatment or 
spontaneously, the skin may get soft and mobile again in a few 
cases, it can only be after some years, and the subjacent tissues 
have then become so permanently damaged that more or less 
deformity and crippling remain. More frequently, in atrophic 
cases, general emaciation sets in, and eventually the patient dies 



DIFFUSE SYMMETRICAL SCLERODERMIA. 627 

marasmic, or falls an easy victim to intercurrent disease of the 
lungs, kidneys, etc. 

Treatment. — The indications are to guard the patient against 
cold, and so prevent aggravation, which nearly always ensues 
after exposure to chilling influences; secondly, to improve the 
general nutrition; and thirdly, to restore the circulation in the 
ischemic area. 

For the first, the patient should be clothed in flannel, never 
allowed to go out in cold winds, and draughts be carefully 
guarded against. 

For the improvement of nutrition, which suffers generally as 
well as locally, cod-liver oil and ferruginous and other tonics, 
which may be suitable to the individual, are the most important. 
Care must be bestowed on the digestive organs, both for the 
sake of improved assimilation, and also because flatulence ma- 
terially aggravates the discomfort of the patient, when the 
trunk is affected. Iodid of potassium, arsenic, mercury, and 
other so-called specifics have been tried extensively and found 
useless; and mercurial inunction has been distinctly injurious 
in some cases, and even in cases in which it has been apparently 
successful, the result was probably due to the friction with an 
oleaginous substance and not to the mercury. 

For the third, shampooing should be systematically and dili- 
gently employed to the affected parts, either after Turkish, but 
not vapor baths, as they are too depressing, or where Turkish 
baths cannot be obtained, with oily substances, such as neat's 
foot or olive oil, or simple ointments. Massage thus carried 
out will often restore mobility, even in very long-standing cases. 
Galvanism is strongly recommended by some, and may be of 
service sometimes, probably by improving the circulation. 

Thyroid extract has been tried because of the not unusual 
co-existence of atrophy of the thyroid, but with very meager 
success,* but Lancereaux and Paulesco had a case of recovery 
in four months, the patient having been previously unable to 
work for two years, with iodothyrin, commencing with 50 centi- 
grams and increasing to 2 or 3 grams. Salicin and salicylate of 
soda appear to have been of great benefit in the earlier stages. 
Where only a limb requires treatment the Tallerman (super- 
heated dry air) local baths would be useful. 

* See Osier on " Thyroid Extract Treatment of Diffuse Sclerodermia," 
Amen Jour. Cut. and Gen.-Ur. Dis.,vo\. xvi. (1898), p. 127. 



628 DISEASES OF THE SKIN. 

CIRCUMSCRIBED SCLERODERMIC 

Synonyms. — Morphea (Gr., ^opq)^ form, or more probably, as 
Wilson suggests, a blotch); Keloid of Addison. 

Morphea is the term in general use for this variety, which 
is still regarded by many authors as a disease separate from 
sclerodermia, but most dermatologists have been convinced, 
by Hilton Fagge's paper in " Guy's Hospital Reports for 1868," 
of its close clinical relationship to sclerodermia, and my own 
observations * have shown that they are anatomically related. 
Circumscribed is more common than diffuse sclerodermia, but 
is still a rare affection. 

Symptoms. — While its general characteristics are the same in 
all cases, it varies very much in many of its details, and presents 
itself in two forms, Hypertrophic and Atrophic, and occurs in 
patches and bands, the patches being the more common. In 
cases in which there are atrophy and pigmentation, only patches 
are present, f 

In a typical case, one or more patches, from half to two 
inches in diameter, appear gradually without symptoms, and, 
therefore, unless they are in an exposed position, often without 
attracting notice until they are fully developed. Each patch is 
of irregular shape, of a dead white or old ivory-white color, 
bordered with a narrow violet, lilac, or pink zone, which close 
inspection shows to be made up of minute dilated vessels. The 
patches are level, or nearly so, with the surrounding skin, gen- 
erally unilateral, sometimes distinctly arranged in the course 
of a nerve area, in the same way as herpes zoster, and may also 
be in herpetiform groups of small spots. A very extensive case 
of guttate spots on the limbs was shown by Pringle.J They 
appear anywhere upon the trunk, but especially on the breasts; 
on the head and face, in the domain of the fifth, especially the 
supraorbital branch; and on the limbs most frequently of all, 
the lower being affected more often than the upper. As a rule, 

* Path. Trans., vol. xxxi. (1880), p. 315. 

f Author's Atlas, Plate XLVIII., shows both the band and patch and 
herpetic forms, and Plate XLIX. an early and late stage of the supra- 
orbital form in the same patient. Hutchinson's Archives, especially vols. 
v. and vi. (1894-5), contain several interesting cases, some illustrated. 

% Derm. Soc. of London, February 4, 1894. 



CIRCUMSCRIBED SCLERODERMA. 629 

there is no difficulty in pinching up the affected skin, as it is 
not adherent to the subjacent tissues, and feels like parchment 
or stiff leather, according to its thickness, which may be greater 
or less than normal, varying even in the same patch. The sur- 
face is dry, the cuticle cracks sometimes, but more frequently 
it is quite smooth from the obliteration of the natural lines 
and the absence of hairs, unless the patch contracts towards 
the center, when there will be minute radiating corrugations. 
When once it is developed the diseased area may remain sta- 
tionary for a long period, and then slowly fade, the skin gradu- 
ally resuming its normal appearance; or the patch may grow 
at the circumference by the formation in its neighborhood of 
minute, pearly white, slightly depressed atrophic spots, about 
one-sixteenth of an inch across, which gradually enlarge, 
thicken, and ultimately coalesce with the major patch. In a 
case of P. A. Morrow's extension took place partly ser- 
piginously with a pigmented zone preceding, partly by throw- 
ing out spurlike processes like a keloid. The duration of the 
disease varies from a year or two to eight or ten, and may be 
attended by the development of fresh patches from time to 
time, and the retrogression of some of the others. As a rule 
there are no attendant symptoms except slight itching (in rare 
instances severe) or the absence of sweating in the patch, but 
the sensibility is very rarely affected, and no special defect of 
health is demonstrably associated with it. 

The band form differs in several respects from the patches. 
Usually single if on a limb, and adherent to the subjacent 
tissues, it is, as the new connective tissue contracts, sunk into 
a sulcus below the surface, but if not adherent, may be raised 
up into a ridge (vide Atlas case and be. cit.). When affecting 
a limb it may extend the whole length of it, or of one of its 
segments, and often presents the aspect of a cicatrix, especially 
when it sinks deeply into the soft structure of the breast or is 
abruptly limited by the middle line on the forehead, or it may 
resemble a hypertrophic scar when it is raised to a ridge across 
a joint. In a case of very slight degree between the brows it 
was only a three-quarter-inch furrow like a deep frown on one 
side of the median line with slight induration. The supra- 
orbital cases generally form two parallel bands, one extending 
from the tip or root of the nose straight up the forehead to 



630 DISEASES OF THE SKIN. 

or beyond the hair margin, but always keeping on one side, 
usually the left, of the median line, while the second band 
extends from the supra-orbital notch upwards. Other divisions 
of the fifth may present lesions. In W. Anderson's case * all 
three divisions of the right fifth, including the mucous mem- 
branes, were involved, and in a case of Hutchinson's only the 
areas of the two lower divisions of the fifth were implicated 
and followed by atrophy and arrest of development. 

Morphea Atrophica. The small, white, slightly depressed 
spots which are the earliest stages of many patches are dis- 
tinctly atrophic {vide Histology), but there are cases in which 
large tracts of skin are atrophic and yet they undoubtedly come 
under morphea, and are not infrequently associated with indu- 
rated patches. The following case is a good example, and will 
serve for a description of this variety: 

Lizzie M., set. nine, was first seen on January 2, 1894. In 
the left groin there was a band two and a half inches wide 
from the crest of the ilium in the mediolateral line to the linea 
alba. It was fairly well defined at the outer extremity, but 
shaded off towards the middle line. The center was white and 
glistening, but with a slightly mottled appearance, while the 
border was half an inch wide and of a dark fawn-colored hue. 
The affected area was slightly sunk below the normal skin, and 
when pinched up was distinctly thinned and dry. Above this, 
at the rib border, was a smaller oval patch with similar white 
area and pigmented border, but the atrophic appearance was 
less obvious. In the right groin was a patch of similar aspect, 
but the white center was distinctly thickened like parchment. 
At the epigastrium was a commencing patch, white in the 
center, with faintly pigmented border. Altogether there were 
seven patches on the front of the chest, but there were none 
elsewhere, and all except the right groin patch were atrophic. 
She had some ordinary psoriasis on the limbs, and subse- 
quently on the morphea patches on the trunk, without any per- 
ceptible difference from its usual characters. The recognition 
of this condition as a variant appertaining to circumscribed 
sclerodermia is important, as such cases are frequently reported 
as a separate disease, and called idiopathic atrophy of the skin 
{vide that disease). In another case, with a large number of 
*Brit. Jour. Der?n., vol. x. (1898), p. 146. 






CIRCUMSCRIBED SCLERODERMA. 631 

both thickened and thinned patches, the patient was positive 
that the thinned patches began as thickened white ones. 

Variations. — Almost every statement applicable to the gen- 
erality of cases may be contradicted in exceptional instances. 
Thus pain and tingling, or itching, have sometimes preceded or 
accompanied the lesion; a patch may be evolved in a few days,* 
and involution, when it does set in, is sometimes rapid; f it may 
cover a large area or be very small; sometimes the patches are 
bilateral or even symmetrically disposed, and occasionally upon 
the median line; or again, instead of being confined to one 
region, they may be scattered over a great part of the body 
surface, J and are sometimes of large size, going quite round 
a limb, for instance. They may be very distinctly depressed 
below the healthy surface, especially in the center, from ad- 
hesion to the tissues below, or raised above it, sharply defined 
at the margin, or merging imperceptibly into the normal skin. 
In some cases there is deep-seated induration which may simu- 
late scirrhus of the skin, especially if it is the abdominal 
wall. 

The violet zone of dilated vessels is often absent, and the sur- 
face, instead of being an ivory white, may be, in parts, pink, lilac, 
or red from underlying vessels being seen through the thinned 
skin, or they may be tinted more or less deeply in various 
shades of yellow, brown, or even purple, green, and black. § 

Many of these variations have been distinguished by various 
names, such as M. tuberosa, lardacea, maculosa, nigra, etc., but 
they are superfluous designations, and are deservedly falling 
into disuse. 

In addition, pearly white, scarlike lines and spots, like true 
striae and maculae atrophica?, may be associated with the more 
characteristic lesions, and telangiectases and pigment patches 
without induration may also be observed, which after a time 
either disappear or develop into the more characteristic lesions. 

* Wm. M., aged eleven, East London Children's Hospital. 

f Miss K., patch on nape, after remaining two years, got rapidly well 
after typhoid fever. 

X A very remarkable case in large bands and curves, in great part sym- 
metrical, is published in Hutchinson's smaller Atlas, Plates CXXXV. and 
CXXXVI. 

§Gaskoin's case, Med. Ckir. Trans., vol. lx. p. 113, is an extreme in 
stance. 



632 DISEASES OF THE SKIN. 

True keloid of Alibert * has occasionally supervened, but this is 
probably accidental. 

Ulceration sometimes occurs. In a case under Tilbury Fox 
which I saw, all the patches, which were numerous on the trunk, 
ulcerated over their whole surface. In a girl of twenty with 
symmetrical morphea of the shins the larger patches ulcerated, 
but not deeply. Jamieson and Fox of New York also report 
ulceration of one or more patches; and Whitfield showed a case 
at the Dermatological Society of London in July, 1901. 

In a case of Prince Morrow's f there were bullae and wide- 
spread ulceration. A case of Sherwell's also had bullae on a 
patch of morphea; and Hallopeau has had a similar case with 
many bullae on and round the sclerodermia. It appears to be 
the rule that if one patch ulcerates, most of the others also 
ulcerate. Considering the amount of vascular blocking, the 
wonder is that ulceration is so rare. 

Changes in other tissues are also occasionally observed, thus 
Streatfeild's case of fifth-nerve morphea was associated with 
exostoses of the lower jaw and palate of the same side. On 
the other hand, atrophy of the subjacent tissues and muscles 
sometimes ensues, especially in band cases, producing deformity 
in the case of a limb; the morbid skin, as in the diffuse form, 
may then be directly adherent to the periosteum. Some cases 
of hemiatrophy of the face are the result of previous morphea 
in childhood having produced arrest of development. 

Whitfield showed a case at the Dermatological Society with 
true verrucose thickening of the epidermis in some patches and 
ulceration in others. 

* Longbottom, age one, E. L. H., a large patch, two inches by one and 
a half developed, unnoticed at first, in right supra-clavicular region; it 
was excised and recurred; the upper portion was again excised and keloid 
developed here; this patch grew larger under observation in the way 
above described. After a time the corresponding position on the left 
side became of a general pinkish hue, with dilated vessels coursing over 
it; on this, small white spots, which gradually enlarged to the diameter 
of one quarter to half an inch, appeared and remained then unchanged. 
The case was under observation between seven and eight years. In 
January, 1885, signs of involution were observed in the oldest patch on 
the right side, but the keloid remained. In Addison's case of Eliz. 
Nicholls keloid followed a scald. In Hutchinson's case, p. 329 of 
" Lectures," keloid developed on the scars of some chronic eruption. 

\ Amer. Jour. Cut. Gen.-Ur. Dz's., vol. xiv. (1896), p. 419, very exten- 
sive and symmetrical distribution (illustrated). 



CIRCUMSCRIBED SCLERODERMIA. 633 

Etiology. — It is more common in females than males, in a 
larger proportion even than diffuse sclerodermia. It may affect 
all ages after the second year; the patches are chiefly seen in 
young adults and the bands in children. 

People of neurotic temperament are most frequently the vic- 
tims, and prolonged anxiety, worry, or other causes of nervous 
depression appear to be predisposing influences; a case of mine 
with a large number of patches dated from a period of pro- 
longed worry. Chills are a possible exciting cause, but much 
less frequently than in the diffuse form. 

Local irritation appears to be an exciting influence some- 
times, and perhaps, if carefully looked out for, would account 
for many that are otherwise inexplicable. Thus cases are re- 
corded as occurring at the spots where the garters were applied 
(Fagge), following the application of a glister (Gillette), the 
friction of a boot,* a blow on the knee,f six months after 
Rontgen ray exposures (Barthelemy), etc.; and it is not im- 
probable that some of the breast cases are due to the irritation 
from the edge of the stays, etc., and some neck cases to the 
friction of the clothing; no doubt the predisposition must be 
present also, but this applies to local causes for many other 
diseases. When all the above conditions have been taken into 
account, it will still be true that no adequate cause can be found 
to account for the majority of cases. 

Anatomy. — The anatomy of circumscribed sclerodermia has been ex- 
amined by myself; sections were made both of the early or atrophic 
stage, and also of the later condition. The results were as follows: 

Epidermis. — There was no perceptible alteration in the epidermis, 
though, of course, there would be in the pigmented cases. In some sec- 
tions there were a few leukocytes in the Malpighian layer. 

* Hutchinson's case, " Lectures," p. 322. 

f Simpson's case, Brit. Med. Jour., June 7, 1884. Also in Dub. Jour. 
Med. Sci., February, 1891, is recorded the case of a boy of eleven, sclero- 
dermia on the left half of the body, the left side of the face, and the left 
extremities, followed a violent blow over the left hip. There was also 
atrophy of left side of the face and limbs, and alopecia in affected regions. 
In Leslie Roberts' case a fall on the abdomen was followed by induration 
at the site of injury, and in two years spread to the right shoulder and 
down the arm in isolated patches, following the branches of the median 
and radial nerves, and produced rigidity and contraction of the thumb 
and index finger. In a case of my own a blow on the center of the head 
in front produced a morpheic band, extending downwards on the fore- 
head to the right of the median line. 



^34 



DISEASES OF THE SKIN. 



Corium.— The papillae were less prominent than normal. In many of 
the vessels of the superficial longitudinal plexus and papillary branches 
(Fig. 31, a) thrombi were found blocking the lumen; in some sections the 
thrombus extended into the minute branches going up to the papilla?, but 




Fig. 31. — Portion of morphea patch X 60, showing papillae obliterated 
and vessels at a, a, a blocked with thrombi. 

more frequently the vessels lying horizontally were alone occluded. In 
one section a small dot, situated at the angle of bifurcation of the vessel, 
suggested an embolus. 

There were always present numerous irregularly branched masses of 
cells, about the size of leukocytes, staining deeply with carmine, but tak- 
ing rather longer to do so than the surrounding tissues, and except when 




JO> 



Fig. 32. — Blood-vessel in a patch of morphea surrounded by a dense 
mass of leukocytes. 



grouped round the sebaceous glands, they mostly lay horizontally, corre- 
sponding to the superficial longitudinal vessels. 

Blood-vessels could frequently be seen going into the mass, and in some 
cases they were connected with the vessels that had a thrombus beyond 
the cell groups; sometimes the vessel appeared to expand at these masses 
as if it were ruptured, and the cells were an effusion from it. In other 
sections vessels might be seen with cells round them (Fig. 32). 

Branching from the cell masses, there was often a reticulum consisting 
of fine fibrils with well-defined borders and cells at intervals upon them, 






CIRCUMSCRIBED SCLERODERMA. 635 

like knots in a net. These cell foci were mainly, as has been said, round 
the superficial longitudinal vessels, the papillary branches being without 
them (except sometimes at their commencement). The process was 
rarely seen in the deep plexus, at least in the early stages, but the con- 
necting branches of the two plexuses were more frequently involved, and 
this cell exudation might be seen occasionally, even in the upper layer 
of the fat. 

Round the sebaceous glands and hair follicles the cell groups and retic- 
ulum were very abundant, chiefly, I think, because there are more 
vessels in the neighborhood of the glands. Cells occurred round the 
sweat duct, but the sweat glands, lying deeper, usually escaped ; and in 
one of the sections, showing the cells round the duct, the gland below 
was normal, and just above it was a deep vessel of the corium running 
into a mass of cells. 

In the later stage the essential feature was the increase of the connective 
and elastic tissues from the fibrillation of the cells seen in the early stage. 
The papillae were nearly flattened out. The dense bundles of connective 
tissue pressed upon and obliterated many vessels, and caused atrophy of 
the sebaceous glands and of the sweat ducts, very few of which were 
seen in this stage. In one section, where the disease was of long duration, 
there was distinct increase in the connective tissue between the acini of 
the sweat gland, and the lining cells appeared to be pressed together. 
Although this implication of the sweat glands was exceptional, yet 
destruction of the ducts necessarily prevented the escape of the secretion, 
which was proved by the injection of pilocarpin subcutaneously close to 
the patch, when, while the skin around was quite wet with perspiration, 
the patch itself was quite dry, except in one very thin part, which lacked 
the smooth, parchment-like feel of the denser parts, and gave a slight sense 
of resistance to the finger passed over it. A zone about half an inch wide 
round the patch was, though moist, decidedly less so than the parts be- 
yond. With anilin violet and iodin, no evidence of lardaceous change 
in the vascular walls was obtained; the cut ends of the muscular fibers in 
the wall of the vessels were quite discernible, though perhaps a little less 
so than in normal vessels. 

Duhring has, since these observations, examined a soft, pliable patch 
from the back, of some months' duration, and found only "a condensation 
of the connective tissue of the corium with a shrinkage of the papillary 
layer." Babinski has also made observations on it. 

The Pathology from my observations appears to be that, 
owing probably to some defect in innervation, cell exudation 
occurs round the vessels, narrowing the lumen, obstructing 
therefore the blood flow, and leading to thrombosis, and some- 
times to a real rupture and effusion. Each atrophic spot seen 
near a growing patch is the base of a cone from which the 
blood supply is cut off, the violet zone being due to collateral 
hyperemia round an anemic area. The patch or atrophic spot 



636 DISEASES OF THE SKIN. 

thickens by the fibrillation of the effused cells. Where the 
arterial supply is completely cut off, an atrophic spot only is 
produced; where it is only diminished, partial atrophy with con- 
nective tissue hyperplasia or morphea is developed. 

Unna * has examined the superficial form which he calls card- 
like sclerodermia and finds a hyperkeratosis of the epidermis 
at the expense of the prickle-cell layer, but no epithelial after- 
growth. The papillary body is flattened, there is a layer of 
dilated tubular lymph spaces below the epidermis, which, filled 
with fluid, reflects the light and causes the milky opacity, while 
dilated vessels shining through the cloudy marginal zone give 
the bluish tinge. 

Inside the patch which occupies the papillary and subjacent 
part of the cutis like a plaque, the capillaries and lymph spaces 
are dilated. The connective tissue cells are increased most 
abundantly in the neighborhood, but not in the immediate 
neighborhood, of the blood-vessels, which are unchanged, and 
there are no cells independent of the blood-vessels, but they 
are very numerous at the margin of the patch, and the lymph 
spaces are enlarged here and at other parts of the patch. The 
thickening of the patch is due to interstitial edema. 

In the thicker form, taken from a not quite typical patch be- 
hind the ear, he found no epidermic changes, but the cutis 
changes, consisting of great increase of connective tissue 
bundles, extended to the adipose layer and included the coil 
glands. The papillae were flattened out to a wavy line, and most 
of the capillaries were obliterated. The collagenous tissue was 
much increased from top to bottom of the cutis, narrowing the 
lymph spaces and blood-vessels and obliterating many of the 
capillaries; but subjacent to the epidermis there was dilatation 
of lymph spaces, but far less than in the superficial form. The 
coats of the blood-vessels were unaltered, but the adventitia 
merged into the surrounding hypertrophic collagenous tissue, 
and the latter stretched and elongated both the coil ducts and 
the hair follicles. 

Unna thinks it improbable that collagenous tissue arises di- 
rectly from the cells and their processes. The veins were much 
dilated at the margin and produced the bluish shimmer. 

Diagnosis. — A well-marked case of circumscribed scleroder- 
* " Histopathology," p. 1103. 



CIRCUMSCRIBED SCLERODERMIA. 637 

mia can scarcely be mistaken for any other affection, the flat, 
ivory-white, circumscribed, violet-zoned, unilateral patches are 
so very distinctive. 

Vitiligo or Icukodcrmia is only a defect in pigmentation, and 
there is no change in the texture of the skin; moreover, it is 
dead white, and morphea has nearly always a yellowish tinge. 

Morphea with raised patches might be something like some 
cases of AUbert's keloid, but keloid is more vascular, harder, and 
has often clawlike processes, which will distinguish it, and the 
latter would never have a nerve distribution. 

The deeply indurated cases resembling scirrhus of the skin 
might be distinguished by the duration and slow development 
of the sclerodermia, and by the smoothness of the affected skin; 
pain from myositis might be present and make the diagnosis 
more difficult, but it would not be of the aching and lancinating 
character of scirrhus. 

Kaposi describes some of the phases of the eruption of non- 
tuberculated lepra under the term morphea;* with these, the 
circumscribed sclerodermia has little in common, except that 
both are probably due to defective innervation. 

The cases of M. alba, lardacea, and nigra, that Kaposi also 
puts down to the account of a local leprosy, seem merely to be 
examples of the affection we have been considering. 

Some of the cases which have been described as hemiatrophia 
facialis, or unilateral atrophy of the face, are doubtless examples 
of fifth-nerve morphea, one such case has come under my 
observation; but others seem to be an independent condition, 
affecting all the tissues, and are due to defective innervation, 
and some are rather instances of arrested development, without 
the skin changes of morphea. Such a case was originally de- 
scribed by Romberg, and was subsequently seen and described 
by Virchow, Eulenberg, Charcot, and latterly Payne, who 
showed the man at the Pathological Society of London in 1881, 
when I saw him. His case is published, with photographs, in 
vol. xxxii. of the Transactions, p. 306. 

Poore, Larde, Fremy, Hammond, Bannister, and Robinson 
have also published cases. 

Mixed Sclerodermia. The cases on record are few in num- 
ber, but have much interest, as they are links connecting the 
* Hebra, vol. iv. p. 156. 



638 DISEASES OF THE SKIN. 

circumscribed and diffuse sclerodermia. Some cases com- 
mence as diffuse sclerodermia, and the patches develop subse- 
quently. Such was the classical case of Eliz. Nicholls,* first 
published by Addison; in this the diffuse sclerodermia was 
unilateral, subsequently morphea developed on the opposite side 
of the face, producing the appearance of hemiatrophy, and 
other patches came on the trunk. 

In Gaskoin's case, already alluded to, patches first came, to 
the number of thirty, which were confidently ascribed to a 
mental shock during pregnancy. There was some defect in 
sensibility in the patches, and much itching. A year or two 
later she was exposed to cold winds, and edema followed. This 
gradually disappeared, and at the same time the patches, which 
had been concave, became level, and atrophic sclerodermia de- 
veloped, spreading from the patches over the whole body sur- 
face except the head. 

In a third case, under Dyce Duckworth, there were two 
patches the size of a penny on the left thigh, and some time 
after she got acute rheumatism, when the patches on the thigh 
spread and got hard, followed by sclerodermia of both arms 
and legs. 

In a case of my own, a youth of eighteen, there were atrophic 
patches on the chest and abdomen, while the deltoid and triceps,, 
especially on the left side, were distinctly indurated and stiff,, 
but the skin over them was unaffected. 

Such a combination naturally produces an irregular distribu- 
tion of the diseased areas, but the course, pathology, and treat- 
ment are the same as in the ordinary types of sclerodermia. 

Prognosis. — The majority, and perhaps all cases, ultimately 
get well, the patches leaving little or no trace of their existence;: 
but the improvement, though occasionally rapid, is often very 
slow and almost imperceptible, and, as a rule, only occurs after 
the patch has been stationary for a long time. Band cases are 
much less favorable than patch cases. Two or three years is 
the time required for a good many cases to get well, but many 
take much longer, cases of twenty years' duration being known, 
and we have no data to guide us in predicting what course any 
particular case will run. Improvement occurs, according to 
Hallopeau, by the substitution of an erythema for discolored 

* Plate XLIV., Syd. Soc. Atlas 



CIRCUMSCRIBED SCLERODERMA. 639 

induration, and subsequently dark-brown pigmentation, finally 
leaving only thinning of the cutis. In one of my cases the 
thickened patches gradually gave way to thinning and pig- 
mentation. 

Treatment. — This is, unfortunately, very unsatisfactory; gen- 
eral measures of invigoration are desirable, as an improved 
general circulation is calculated to improve the local circula- 
tion. No known local means have been as yet proved to influ- 
ence the disease for good. Galvanization has been suggested, 
but it should be applied in the neighborhood, and not over the 
patch, as anything that irritates the diseased area induces further 
thickening. The procedure is the same as for hyperidrosis. 
Brocq has had good results in eight cases with electrolysis.* 
Needles attached to the negative pole were introduced into the 
border of the patch for fifteen or twenty seconds, with a current 
of five to ten milliamperes; patches at a distance from the one 
treated also improved. Darier has also had a successful case. 
Shampooing the limb or other region affected should be also 
employed in these cases, as in diffuse sclerodermia, and where 
the disease is over a superficial bone, as on the forehead, careful 
massage will often prevent the skin adhering to the bone and 
producing a disfiguring sulcus. 

Neisser has obtained success by injecting a ten per cent, solu- 
tion of thiosinamin subcutaneously near or under the patch. 
Herxheimer has also used it in three cases with advantage. In 
view of its efficacy in keloids and hypertrophic scars and the 
induration of chronic dermatitis, it is probable that it will be 
advantageous here also. I have not used it long enough to 
speak from personal experience. It failed in a bad case on the 

shins. (See Injection Treatment in Appendix for the formula, 
etc.) 

* " Traitement des Sclerodermies en plaques et en bandes par l'eleo 
trolyse," Annales de Derm., etc., vol. ix. (1898), p. 113. 



640 DISEASES OF THE SKIN. 

SCLEREMA NEONATORUM. 

Synonyms. — Sclerema of the newborn; Sclerodermia neona- 
torum; Induratia telse cellulosse; Fr., Algidite progressive; 
L'endurcissement athrepsique (Parrot); Ger., Das Sclerem 
der Neugeborenen. 

Definition. — An induration of the skin, congenital or occurring 
soon after birth. 

Like sclerodermia, the name is indicative of induration, but 
the pathology and symptoms are very different, and it is advisa- 
ble to use this term to mark the distinction. Under the term 
sclerema neonatorum two distinct affections have long been 
confused, viz., " Sclerema " and " Edema " neonatorum. Scle- 
rema * was first fully described by Underwood f and Denman 
at the end of the last century, and soon after a French physician 
to the Hopital des Enfants Trouves observed the affection now 
known as edema, but mistook it for Underwood's disease, and 
the error was perpetuated by other observers up to 1877, when 
Parrot J pointed out that they were distinct affections, a view 
which is now generally acknowledged to be correct. 

It may be primary or secondary, be present at birth, or come 
on within the first ten days of life, rarely later. § 

The morbid process usually commences in the lower limbs, 
then spreads to the lumbar region, over the rest of the back, 
then to the chest, and then gradually over the rest of the body 

* The first known case occurred at the Stockholm Hospital in 1718. 
According to the midwife it was born alive, and died soon after birth. 
It is recorded by Usenbenzius of Ulm, " Partus Octimestris Vivus Frigi- 
dus et Rigidus," in Ephe7nerid. acad. natures cur. centuria, ix., obs. 30, 
p. 62, December, 1722. Schurigii quotes the same case in his " Embry- 
ology." 

f Underwood, "Diseases of Children " (first ed., 1784, p. 76), calls it 
"hidebound." 

% " L'Athrepsie," by J. Parrot, p. 116 (Masson, Paris, 1887). 

§ Three cases of a late chronic variety with paralysis are related by 
Angel Money, Lancet, October 27, 1888. 

Soltmann, " Ueber Sklerema neonatorum." Reprint from article in 
Eulenburg's Real-Encyclopadie, 1889. Gives a large number of refer- 
ences. 

Somma, " Lo sclerema dei Neonate," Naples, 1892. Ballantyne's 
" Diseases of the Fetus," vol. ii. 



SCLEREMA NEONATORUM. 641 

surface, so that it is generally universal by the fourth day; in 
a few cases it begins on the face and spreads from above down, 
or again it may stop at some point short of completeness. At 
first the skin is of a yellowish-white or waxy-looking, and feels 
like thick leather, but the whiteness gives way to a slightly 
livid tint, and the skin becoming adherent to the subjacent 
parts, as well as rigid, it can no longer be pinched up, and pres- 
sure with the finger produces no pitting. The skin is tense, 
loses its natural wrinkles, is cold and hard, and since the limbs 
are fixed and the child lies with the eyes closed and motionless, 
except that very slight movements may be discerned in the 
thorax and face, it resembles a marble figure, or as if it were 
in a state of rigor mortis. So rigid is the body that it may be 
raised with one hand, and will still retain the horizontal posture, 
without flexion. Browning * of New York records a case of 
sclerema with opisthotonos without any meningitis. The face 
is rarely absolutely rigid, but the stiffness of the lips and cheeks 
prevent sucking and deglutition, and the mouth cannot be 
opened, which has given rise to the erroneous idea that trismus 
was present. The pulse falls to sixty a minute; the respirations 
to fourteen or even ten, and very shallow; and the temperature 
is several degrees below normal; the cry is reduced to a feeble 
moan; and what little vitality remains is generally completelv 
extinguished by the seventh day or even earlier. The congenital 
cases are either still-born or die within forty-eight hours. 

In partial cases recovery may occur, but the induration may 
last for months. In A. Garrod's case \ the disease began, the 
nurse said, three or four days after birth with purple patches 
of induration on the buttocks. When seen at seven weeks old, 
the induration was over the back of the trunk and limbs very 
symmetrically distributed and with islands of healthy skin; 
none on the anterior surface except small islets on the fore- 
head. The induration took six months to disappear. The rectal 
temperature varied from 98.6 to 100.4. Similar cases are on 
record. 

Etiology. — The primary cases are either congenital or begin 
in the first few days after birth, without previous illness; the 

*Jour. Cut. and Gen.-Ur. Dis., vol. xviii. (1900), p. 563. 
f Clin. Soc. Trans., vol. xxx. (1897), p. 129. A previous case was pub- 
lished in the Lancet, May 4, 1895, p. 1103. 

41 



642 DISEASES OF THE SKIN. 

secondary cases are the sequel of causes which depress vitality, 
such as diarrhea or other bowel complaints, or pulmonary 
affections, such as atelectasis or pneumonia, with extensive col- 
lapse. Parrot regards it as one of the phenomena apt to occur 
with malnutrition from bad feeding and defective hygiene — 
athrepsy, as he calls it in a word; and that this and overcrowd- 
ing are predisposing causes. Underwood confirms this when 
he calls this essentially a hospital disease, at a period when 
hospital hygiene was much worse than at the present day. 

Pathology. — The other writers having mixed up edema and 
sclerema their observations must be disregarded. 

Langer, while distinguishing the edematous cases, regards 
the other cases as fat sclerema, and ascribes the sclerema to 
solidification of the fat. He states that the fat of the new-born 
melts at 130 F. and is solid at 89.6 F., while that of adults 
melts at 197° and solidifies below 32 F. This difference is due 
to the fatty acids being in excess of those in adults, as 31 per 
cent, to 10 per cent., and he states, therefore, that any cause 
which depresses the temperature below the solidifying point of 
the fat will produce the disease. In such cases there will there- 
fore be no histological changes, but the theory is not entirely 
satisfactory and scarcely accounts for the congenital cases. 

On the other hand, Parrot regards the condition as a conse- 
quence of desiccation of the tissues from the drain of the diar- 
rhea, etc., and states that the anatomical changes are very 
definite and easily recognizable. He says: 

" The skin as a whole is notably diminished and thinned, but the horny- 
layer is unchanged, and only looks thicker by contrast with the thinned 
rete and corium. The outline of the rete cells is scarcely visible, as the 
cells are compressed into a compact mass. The connective tissue corpus- 
cles of the corium are well denned, and the connective tissue trabecular 
appear more numerous and thicker than usual. The islets of fat are 
smaller, and the contents of the vesicles so diminished as to show the 
nucleus or even to leave the vesicle empty. The vessels are much con- 
tracted, especially those of the papillary layer, in which their lumen is 
invisible. There is, therefore, a drying up of the skin, thickening of the 
layers, and some diminution of the fat, but there is no true sclerosis, nor 
serous infiltration." Ballantyne's* observations confirm Parrot's, on the 
whole, except that there is. he thinks, an increase of the connective tissue 
which subdivides the fat masses into smaller clumps. 

* Brit. Med. Jour., February 22, 1890, p. 403. 



EDEMA NEONATORUM. 643 

Previous observers have either not found any changes or 
described those of edema neonatorum. The diagnosis, prog- 
nosis, and treatment will be considered in connection with 
edema. 

EDEMA NEONATORUM. 

Synonym. — Edema of the newborn. 

Definition. — A subcutaneous edema, with induration, affecting 
the newborn infant. 

This is a very rare disease in England, but is more common 
abroad, and we owe its delineation chiefly to French observers. 

The disease may be present at birth or begins before the third 
day of life, with drowsiness; then the extremities, especially the 
le^s, are swollen with edema, cold and livid. The edema 
spreads upwards to the thighs; the hands are next affected; and 
then the genitals and back. It is marked on the soles and nates, 
which parts are red and hard. Like all edema the swelling is 
greatest in the most depending parts, but pitting is only pro- 
duced by prolonged pressure and the tissue feels hard or at 
least doughy. 

The drowsiness becomes more marked, the pulse weak, the 
breathing short and shallow, and this feeble spark of life is often 
put out by some complication, such as pulmonary affections, 
especially those with collapse, diarrhea, or convulsions, and in 
a few instances, by parenchymatous nephritis. 

Variations. — The edema may begin in the back or face and 
the swelling of the hands may follow immediately upon that of 
the legs. In very exceptional instances there may be a high 
temperature instead of a low one, and a jaundiced hue may re- 
place the lividity shortly before death. Associated with it have 
been noted icterus, erysipelas, pemphigus, furunculosis, and 
Demme records purpura and disseminated gangrene. 

Etiology. — It almost invariably occurs in infants which are 
premature or of feeble vitality from some other cause, and 
atelectasis is present in many instances. Soltmann suggests 
that puerperal infection may play a part. Bad feeding of the 
mother and child, and exposure to cold immediately after 
birth, are also fruitful causes of the disease. 

Pathology. — This is not known, but presumably the condition 



644 DISEASES OF THE SKIN. 

is directly due to the feeble circulation and defective aeration 
of the blood, at a period when vital resistance is always small. 
But this does not adequately explain the whole process. Leon 
Dumas * considers it analogous to phlegmasia dolens, and a 
thrombus in both femoral veins has been discovered in one case, 
Ballantyne f considers it comparable to adult anasarca, and 
that it may be of renal, cardiac, or pulmonary origin. 

Anatomically there is invariably yellow serous effusion into 
the cellular tissue, and the fat is of remarkable density and of 
a yellowish-brown color. The liver is very large and the lungs 
congested, and Ballantyne found nephritis. 

Diagnosis. — Sclerema and edema possess many factors in 
etiology and all the signs of depression of the vital organs in 
common, viz., lowered temperature; steadily increasing debility; 
imperceptible pulse; absence of the second sound of the heart. 
They differ in the following points: In sclerema, in the vast 
majority of cases, the disease is general; the skin is tense, hard, 
and waxy in color at first, unpittable, and adherent to the sub- 
jacent tissue. Edema is less general, the skin, markedly livid 
from the first, is not so hard, pits with firm pressure, can be 
pinched up, and the swelling is always greatest in the most 
dependent parts. In sclerema the joints and jaw are stiff; not 
so in edema, or only in a moderate degree. The early age of 
their occurrence will distinguish them from sclerodermia, of 
which no case under thirteen months has yet occurred. Bar- 
low, I from a case of sclerema under his care, which was partial 
in its distribution and recovered, considers that the color of 
the patches in sclerema is " bluish-red or of a deep copper tint, 
while in sclerodermia either the color does not differ from the 
healthy skin, or is of a whitish-tallowy character." In a partial 
case which I saw with my colleague, Dr. Blacker, § at five weeks 
old, the infant was in good condition generally, there was no 
discoloration except where the napkin came, and much of the 
induration was like plaques in the skin, which pitted with diffi- 
culty. 

This distinction does not bold good for the majority of cases, 

for as Underwood pointed out in his original description the 

* Quoted in Lancet, November 26, 1887, p. 1081. 
f Loc. c/f., Lancet, 1890. 
t Clin. Soc. Trans, vol. xvi. (1883), p. 262. 
%Brit. Jour. Derm., vol. x. (1898), p. 87. 



ELEPHANTIASIS. 645 

skin in sclerema is of a waxy or yellowish-white. But for the 
absence of pitting, Barlow's case appears more like edema. In 
Parrot's case sclerema followed edema neonatorum. 

Prognosis. — Sclerema is invariably fatal if it is complete, the 
infant surviving for only a few days; but in a few cases it is 
incomplete,* and then recovery may take place. In edema the 
prospect is not quite so hopeless, though always serious, and 
the duration is usually greater than that of sclerema. 

Treatment. — The indications are the same for both, viz., to 
raise the body temperature to the normal and to administer 
nourishment. For the first, the child should be wrapped in 
cotton-wool and surrounded by hot-water bottles in a warm 
room; or, where practical, a box apparatus, on the principle of 
an incubator, would be advantageous. The child, being unable 
to suck, must be fed either by passing a small stomach pump 
tube through the nose, injecting the aliment (such as pep- 
tonized milk and white wine whey), or by Scott Battams' more 
simple plan of injecting the food with a glass syringe, to the 
nozzle of which an india-rubber tube is attached, which is passed 
into the pharynx. Friction of the limbs with oil, rubbing to- 
wards the heart, is useful in the improvement of the circulation. 



ELEPHANTIASIS.f 

Deriv. — SlicpaZ, an elephant. 

Synonyms. — Elephantiasis arabum; Elephant leg; Barbadoes 
leg; Bucnemia tropica; Morbus elephas; Pachydermia; 
Spargosis; Phlegmasia Malabarica; Hernia carnosa; Ele- 
phantiasis Indica: Fr., Elephantiasis; Ger., Elephantiasis. 

Definition. — A chronic endemic or sporadic disease, consisting 
of a hyperplasia of the skin and subcutaneous tissues, due to 
blocking of the lymphatic channels, and resulting in enormous 
hypertrophy of the affected part. 

The term elephantiasis has been used as a generic term for 
diverse diseases, such as lepra (elephantiasis grsecorum), der- 

* Barr's case, Brit. ^Ted. Jour., May 4, 1889. 

\ Literature.— Author's Atlas, Plate I., a leg from Barbadoes, illustrates 
the smooth variety; Plate LI., Fig. 1, a sporadic case of the warty or 
papillary variety, reduced half-size to get it into the plate. Vincent 



646 DISEASES OF THE SKIN. 

matolysis, the huge symmetrical lipomata which grow about the 
neck chiefly in chronic alcoholics, as well as the disease under 
discussion, with the single feature of the enlargement of some 
part as the only link between them; but it is better to restrict 
the term to the one affection for which it is fairly appropriate, 
and it will not then be necessary to use any specific addition, 
such as Arabum. 

Symptoms. — The disease is endemic or sporadic, differing in 
the initial and intercurrent symptoms, but practically identical 
as regards the ultimate result to the affected part, except that 
in the endemic form usually the limb is very large and smooth, 
while in the sporadic form the surface of the limb is papillary 
and rough. The sporadic form alone occurs in England, and is 
one of the uncommon forms of skin disease. A congenital form 
also exists. 

As seen in tropical or subtropical climates, where it is 
endemic, the onset is often attended with severe febrile symp- 
toms, sometimes termed " elephantoid fever." There are intense 
lumbar pain, nausea, or even vomiting, and shivering, followed 
by high fever, and this again by sweating. If the leg be attacked 
there is erysipelatous-like redness and rapid swelling, with pain- 
ful tension, from the great infiltration into the cellular tissue, 
and when the lymphatics are much involved, there is a clear or 
milky discharge. If the scrotum is the part affected vomiting is 
nearly sure to be present, with intense pain in the groin, testes, 
and along the spermatic cords, which are swollen, with external 
redness, and the acute formation of hydroceles, while the ab- 
dominal rings may be so much stretched by the swollen cords 

Richards on " Elephantiasis Arabum " in Fox and Farquhar's " Endemic 
Skin and Other Diseases," App. VIII., p. 126 (Churchill, 1876). Lecture on 
" Elephantiasis Arabum," by Sir Joseph Fayrer (March, 1879); also Path. 
Trans., 1879, and " Relations of Filaria sanguinis hominis to the Endemic 
Diseases of India" (a good resume, with numerous references), Lancet, 
February 8, 1879. Writings by P. Manson in eighteenth issue of Chinese 
Med. Rep., and many previous papers on filaria disease, showing life 
history of the parasite, and relation to E. Arabum and other diseases. 
"Die elephantiastischen Formen," F. Esmarch and D. Kulenkampff 
(Hamburg, 1885), — a richly illustrated monograph, in which elephan- 
tiasis is used in its widest sense for numerous hypertrophic diseases, con- 
genital and otherwise. " Elephantiasis Arabum," Hans von Hebra 
(Wien, 1885). Manson's "Tropical Diseases," second ed. (1900), p. 505, 
for pathology, but the whole chapter on Filariasis should be read. 



ELEPHANTIASIS. 647 

as to lead to hernia, after the subsidence of the swelling 
(Fayrer). Under suitable treatment the febrile symptoms sub- 
side, leaving the limb slightly larger than before. In some cases, 
although the periods of quiescence last for months, the parox- 
ysms are severe; while in others again the paroxysms are of 
slight intensity, and at long and irregular intervals, and the 
growth is proportionately slow and less developed. In 3^ per 
cent, there is no fever, and in many the enlargement of the 
axillary and inguinal glands precedes the fever. In rare in- 
stances there is continuous increase without constitutional dis- 
turbance. In this country an attack, or repeated attacks, of 
erysipelas may be the starting factor, and there will then be cor- 
responding febrile symptoms in proportion to the extent and 
intensity of the erysipelas ; but in others the development is very 
slow, and constitutional symptoms are absent. No symptoms 
corresponding with elephantoid fever form a part of the morbid 
phenomena in this country, nor are cases of rapid or very ex- 
treme development seen here. 

When pretty fully developed the limb presents the following 
aspect, taking the leg, which is the most common position, as 
the type: the limb below the knee is enlarged to three or four 
times its normal girth, and although some edema is present, it 
requires strong pressure to produce pitting, and the greater 
part of the increased bulk is solid, and generally extremely 
hard and unyielding. 

Owing to the swelling of the tissues on each side of the nat- 
ural folds these form deep sulci, especially marked at the bend 
of the joints, and the swollen parts being in contact, the surface 
is covered with a moist, slimy, and offensive fluid, consisting of 
decomposing sweat, sebum, and sodden epithelium. Reddish or 
deep brown pigmentation of the whole limb, deepest at the 
lower part, is generally present. The surface of the limb is quite 
smooth, if only the trunk lymphatics are blocked, but if the 
superficial ones are also involved, the surface will be irregular, 
with varicose lymphatics, which form wormlike projections 
or deep-seated vesicular protrusions upon it; or, as it usually 
presents itself in the sporadic form, in which there is chronic 
or recurrent inflammation of the surface lymphatics, there will 
be patches of hypertrophied papillae, which form soft or warty, 
elevated plaques, covered with thick horny or sodden epidermis; 



648 DISEASES OF THE SKIN. 

these are especially common on the dorsum of the foot, and 
there is boardlike hardness of the subjacent tissues. 

As a rule there is no pain or other sensory disturbance, except 
during the febrile exacerbations, or from complications, of 
which the most common is eczema, chiefly seen in the smooth 
limbs, accompanied by much itching; varicose ulcers also are 
frequent. In the inflammatory attacks the pain, heat, and 
tension may be very great; sympathetic gland irritation is gen- 
erally present, and the dilated lymphatics are tender and painful, 
and so turgid as often to rupture spontaneously in various parts 
of the limb, or to be opened by the patient himself, to obtain 
relief from the tension. The discharge is a clear or milky chyle- 
like and coagulable fluid, the loss of which may be a serious 
drain on the patient's vitality; while the weight or bulk of the 
limb is often so great an inconvenience that the patient is glad 
to have it removed. 

Variations. — While in this country the vast majority of cases 
afTect one leg, very rarely both, in countries where it is endemic 
both legs. are often involved, and if only one, the right more 
often than the left; the scrotum and penis, or the labia and 
clitoris, are only a little less frequently affected. Filarial thick- 
enings of circumscribed portions of skin sometimes occur, and 
even pedunculated tumors, chiefly on the anterior part of the 
thigh, are said to be not uncommon in Fiji and other places. 
Even in England other parts are occasionally involved; thus I 
have seen it in the arm, forearm, and hand, in a lad who had 
had repeated attacks of erysipelas;* in both ears in a woman 
who had suffered from eczema of, and behind, the ears on and 
off for twenty years; in the scrotum in a home case of Dr. S. 
Mackenzie, and in a case of my own where the man had lived 
in Smyrna; in the lips — chiefly in the upper one — in a male 
patient of Mr. Harwell, for which he tied the facial arteries with- 
out much benefit; while Hebra and Kaposi mention similar 
enlargement of the cheek and nose; and in India Vincent 
Richards saw the whole left side of the face, and Ghosal, the 

*A well-marked case of hand and arm elephantiasis with papillary 
hypertrophy is published by Hover in the Buffalo Med. and Surg. Jour., 
May, 1886, with woodcut. Thibierge also records a case involving the 
upper limb in connection with chronic scrofulous lupus and recurrent ery- 
sipelas. " Extrait des Bulletins et Memoires de la Societe Medicale des 
Hopitaux de Paris." seance du 15 Mai, 1896. 



ELEPHANTIASIS. 649 

female breast affected. In Felkin's case * a Eurasian woman, 
the upper segments of all the limbs and the whole trunk, except 
a small median portion back and front, were involved. It 
began in early life. Considerable improvement was produced 
by rest, massage, the constant current, and tonics. In most of 
these cases the surface is smooth, though often highly vascular. 

It must be borne in mind that there are all grades of elephan- 
tiasis, from moderate thickening of the skin and subcutaneous 
tissue up to enormous enlargement, and similarly great varia- 
tions in aspect exist, according to the papillary hypertrophy 
or lymphatic and blood-vessel varicosity, and their relative pro- 
portions. 

For example, the scrotal tumor may be so large as to hang 
quite down to the ground, and some of them have weighed 
over a hundred pounds, the largest on record having been 224 
pounds. On the other hand, in the form known as " lymph 
tumors," " lymph scrotum, or nevoid elephantiasis," the en- 
largement is only moderate, but the lymphatic vessels and 
spaces are much dilated, make the surface irregular, and during 
the paroxysmal febrile attacks become turgid, and may rupture, 
discharging milky or serous fluid. 

Congenital Elephantiasis. — The characters of most cases differ 
from the acquired disease. The most common is a vascular 
form, elephantiasis telangiectodes, applied by Virchow to rare 
cases of congenital origin, but later development, in which there 
is nevus development of the deep vessels, with overgrowth of 
the tissues from excessive nutrition. There is but little external 
change except enlargement, but the limb has a lobulated feel, 
and firm pressure empties the enlarged vessels temporarily, like 
squeezing a sponge. I examined and photographed a case of 
this variety by the kindness of Dr. Savill. f The condition 
approaches fibromatous enlargement in some respects. E. 
lymphangiectodes is another form, and has been associated 
with E. telangiectodes in one or two instances. 

Moncorvo of Rio Janeiro J has recorded a series of cases in 
infants which had developed in utero, but had increased after 

* Edin. Med. Jour., 1889, p. 779. 
\ Lancet, November 8, 1891 (" Hospital Mirror "). 

% Annates de Derm., etc., vol. iv. (1893), p. 233; vol. v. (1894), p. 186; 
and vol vi. (1895), p. 965. 



650 DISEASES OF THE SKIN. 

birth. In most cases the limbs, though much deformed, were 
smooth like the adult endemic form. He never found any 
filaria, and attributed the solid edema to streptococci. 

In Europe this kind of case is quite exceptional, but Mainzer * 
records such a case affecting the left upper extremity, both legs, 
the right foot, external genitals, etc. The cause was obscure. 
Meige's eight cases in four generations of " chronic hereditary 
trophedema " were of similar character. Nonne f published 
four congenital cases affecting both limbs. They were all from 
the same family, in whom nine members through four genera- 
tions were affected, and there were papillary growths. In 
Spietschka's case J the face, three limbs, and the genitals were 
affected. Barwell § has published an extreme case of congenital 
right-sided hypertrophy of the face. 

The persistent edema of the face, sometimes called " solid 
edema," seen in the subjects of recurrent erysipelas or lymphan- 
gitis, is really only an inchoate form of elephantiasis. It has a 
superficial resemblance to myxedema, but lacks the complex 
symptoms of that disease, and the cheeks are pale instead of 
being telangiectic. It may be seen in the lower lip as a result 
of repeated or chronic ulceration of the lip, syphilitic or other- 
wise. 

Etiology. — Elephantiasis attacks both sexes at all ages, but is 
more common in men, as three to one (Waring), and in adult 
and middle life. It may also be congenital. It is also much 
more common in the dark than the fair races, and is endemic 
in India and the Malayan Peninsula, in China and Japan, in 
Egypt and Arabia, in the West Indies and parts of America, 
while it occurs sporadically in all parts of the world, except in 
the Arctic or Antarctic regions. Damp malarious regions in 
the neighborhood of the sea are especially favorable to its de~ 
velopment, and Manson thinks its distribution is identical with 
that of the mosquito; certainly removal from the endemic area 
is always advisable, and arrests the progress of the disease, 

* Deutsch. med. Wock., vol. xxv., July 6, 1899, P- 43°. Abs. in Brit. Med. 
Jour. Supp., September 2, 1899. 

\ Archiv f. path. Anat., vol. cxxv. Heft 1, p. 189, illustrated. Meige's 
cases are in Nouvelle Iconographie de la Salpetriere No. 6, 1899, p. 453. 
Abs. Brit. Jour. Der?n. t vol. xii. (1900), p. 372. 

% Archiv f. Derm. u. Sjph., vol. xxiii. (1891), p. 741, illustrated. 

%Path. Trans., vol. xxxii. (1881), p. 282. 



ELEPHANTIASIS. 651 

which returns if the patient goes back to the malarious district. 
Bad living is supposed to be an important predisposing element. 
V. Richards found that in 236 persons, in seventy-three per 
cent, one or both parents were affected; but from its pathology 
tropical elephantiasis is not likely to be hereditary, and the coin- 
cidence is probably due to their being exposed to the same influ- 
ences. Similarly, leprosy and this form of elephantiasis have 
no relationship, but both occurring in similar climatic conditions 
they have been found in the same individual — as often as six 
per cent, in 636 cases (Vincent Richards). 

Pathology. — The disease is consequent upon occlusion of the 
lymphatic channels of the part affected, independent of the cause 
or nature of the obstruction, and whether it is at the trunk or 
periphery of the lymphatic circulation. 

In the endemic cases the researches of Manson, Lewis, Ban- 
croft, and others, go to prove that the obstruction is due to the 
parent worm, filaria Bancrofti,* blocking up the main lymphatics 
of the part. Manson's account is as follows: "The parent 
worms live in the lymphatic trunks, discharge their ova into 
the lymph stream, by which they are carried to the glands and 
arrested there, until they hatch ; the embryos then enter the gen- 
eral circulation along the lymph vessels, residing in some organ 
during the day and circulating in the blood at night; mosquitoes 
abstract them from the blood and act as the intermediary hosts, 
and transfer them to water, to reach man again when he drinks 
the contaminated fluid. Chylous hydrocele, chylous ascites, 
chylous diarrhea, lymph scrotum, as well as other affections, such 
as chyluria, varicose groin, and axillary glands, with hematozoa, 
are produced by partial obstruction of the lymph circulation in 
the glands, directly, by their size, or indirectly, by exciting in- 
flammation. 

" Varicosities of the veins, glands, and different lymphatics 
result, and the lymphatic circulation is carried on by anasto- 
moses, enabling the embryos therefore to get into the blood; 
but where the obstruction is complete, either the vessels are so 

*The filaria nocturna is the embryonic form of this, and is the original 
filaria sanguinis hominis discovered bv Lewis; but other blood worms 
having been found. Manson re-named the first F. nocturna, while others 
are F. divina, perstans. Demarquaii, Ozzardi, and Magalhaesi. Only F. 
nocturna and perstans have a pathological importance. 



652 DISEASES OF THE SKIN. 

distended that they rupture, and lymphorrhagia of a more or 
less persistent character results, either from the scrotum or leg, 
with varicose glands and filaria embryos in the glands, but none 
in the blood; or the lymphatics do not rupture, there is complete 
stasis of lymph, with accumulation on the distal side of the 
glands, with solidification of the tissues producing elephantiasis; 
the course of events being, Manson says, k ' parent female filaria 
in the lymphatic system of the affected part; injury of the filaria, 
hence premature expulsion of ova; embolism of lymphatic 
glands by ova; lymph stasis; recurrent lymphangitis, leading to 
inflammatory hypertrophy of the parts; here again, no embryos 
are found in the blood or gland lymph, as they cannot get past 
the glands, and the parent worms also die from the accumulation 
of lymph and embryos,"* and may produce abscess and lym- 
phangitis. Interesting as this is, however, it is only one of many 
causes of obstruction to the lymphatics; in sporadic cases, in 
temperate climates, the same result is brought about in a differ- 
ent way. Erysipelas, either as a severe and diffuse cellulitis, or 
from repeated attacks, is one of the most common causes of 
lymphatic obstruction. Sabouraud f examined and cultivated 
the serum during the attacks of lymphangitis of a case of E. 
nostras, and invariably found streptococci of erysipelas, but the 
cultures in the intervals remained sterile. Phlegmasia dolens is 
another disease which may occlude the trunk lymphatics and 
lead to elephantiasis; while long-continued or repeated attacks 
of eczema of the leg are responsible for a certain number, 
though they are seldom extreme instances of the affection; in 
this form the peripheral lymphatics must be the first to get 
obstructed. In some cases, again, the pathological factor can- 
not be recognized, and we know only the result of the obstruc- 
tion. Favoring influences are a pendulous condition of the 
part, e. g., flabby breasts, and in the case of the lower limbs want 
of exercise, increasing the natural difficulty of the circulation in 
the dependent limb; in short, anything hindering the venous as 
well as the lymphatic flow. 

* Manson finds that the embryos of three species are to be found in the 
blood stream : the filaria sanguinis hominis of Lewis and the filaria san- 
guinis hominis major and minor. The last two have been found in 
Africans; the first in Asiatics and Americans {Lancet, January 3, 1891). 

\ Aiinales de Derm., vol. iii. (1892), p. 592. 



ELEPHANTIASIS. 653 

Anatomy. — This has been studied by Virchow, Kaposi, myself, and many 
others, with general agreement. On section, the surface is yellowish- 
white, fibrous, and fatty; in some parts gelatinous, in others, white, or 
yellowish-white, lymph exudes on pressure. The chief change is in the 
subcutaneous tissue, which is enormously hypertrophied from increase of 
fibrous tissue in a more or less developed stage, most of it being distinctly 
in fibrous bands or networks, while other parts are gelatiniform, with soft 
fine fibers, and many nuclei and cells. This is contained for the most 
part in loculi composed of more advanced fibers; the corium is increased 
in thickness, but in a less degree; the epidermis is also proliferated, the 
skin changes being most marked where there are papillary growths. 
Both blood-vessels and lymphatics, and often the nerves, are enormously 
enlarged, and in advanced cases all the structures are red, the muscles 
undergoing fibro-fatty changes, the fascia being much thickened, and the 
bones enlarged, either regularly or irregularly, into exostoses. 

Diagnosis. — When the disease is fully developed the enormous 
enlargement, the hardness with firm edema, and, if the surface 
is affected, the varicose lymphatics and papillary hypertrophy 
afford no room for error. The " elephantoid fever," in coun- 
tries where it is endemic, should excite suspicion in the early 
stage; it differs from remittent fever in the cold and hot stages 
being very intense, lasting four or five days, while the intermis- 
sions vary from a fortnight to several months. In this country 
if a part is subjected to repeated attacks of erysipelas, more or 
less connective tissue hypertrophy is pretty certain to ensue. 

Prognosis. — In the early stage, if the patient can be removed 
from the endemic district, the disease may be checked, and even 
in sporadic cases much may be done to check it, but there is no 
absolute cure, except when the disease is so situated that the 
overgrowth can be removed, as in elephantiasis of the genitalia. 

The enormous size that may be reached has already been 
alluded to, but life is rarely endangered, though much burdened 
by the " too, too solid flesh," which may clog the patient for any 
period up to forty years or more. 

Treatment. — During the fever of endemic cases Fayrer recom- 
mends saline aperients, with opiates to procure sleep, and lo- 
cally, fomentations and soothing measures generallv, followed 
by quinine, or, if there is much anemia, iron; change of climate 
is, however, of the first importance — to Europe, if the victim 
be a European, or, at least, away from the endemic neighbor- 
hood. The scrotal tumors may be removed by the knife; even 
those over one hundred pounds have been successfully re- 



654 DISEASES OF THE SKIN. 

moved, dissecting out the penis and testicles by incisions along 
the course of the cords and dorsum penis, and taking away the 
whole of the affected skin, otherwise recurrence is likely to take 
place. The tumor should be drained of blood for some hours 
before operation, and then an elastic bandage applied, and a 
ligature put on at the base, as the number and size of the ves- 
sels are very great. The penis and testicles get covered in with 
cicatricial tissue in from two to four months. In the leg an 
attempt has been made to starve the growth by ligaturing the 
femoral artery, but has seldom been permanently successful, and 
no one advocates this treatment now, the more so, as compres- 
sion of the main artery is fully as useful. V. Richards strongly 
recommends this, combined with an exclusively milk diet; but 
most relief can be afforded by Martin's india-rubber bandage, 
carefully and firmly applied during the day, and by the use of 
a light pervious one at night ; this relieves the edema, and, except 
in extreme cases, reduces the limb so much as to enable the 
patient to get about with comparative ease; of course, this 
treatment is only palliative, as the limb, if left alone, speedily 
regains its previous size. 

In the cases with warty and soft papillary growths there is 
often an extremely offensive discharge from the latter, due to 
sodden and decaying epithelium. Sprinkling the surface with 
iodoform, or an equivalent, such as europhen one part and 
boric acid three parts, corrects the fetor and, combined with 
pressure, assists in producing atrophy of the overgrowth; 
where there is a hard warty covering, salicylic acid is the best 
adjuvant. Various other means have been recommended; ab- 
sorbent remedies, such as iodin and mercury, the latter as a 
Scott's dressing bandaged on, having been most highly spoken 
of, but the improvement is only temporary, and probably due 
chiefly to the rest and bandaging; indeed, the pathology of the 
disease suggests the futility of all such measures. When the 
lymphatics are very turgid, during the febrile exacerbations, 
opening some of them gives great relief by diminishing the 
tension ; at the same time it is almost equivalent to bleeding the 
patient. 



CLASS V. 
ANOMALIES OF PIGMENTATION. 

Pigmentation of the skin may be either excessive or de- 
ficient, and each of these anomalies may be congenital or ac- 
quired. Congenital excess is seen in pigmentary nevi, con- 
genital deficiency in albinism. 

Acquired excess is idiopathic or symptomatic, and may be 
either in small spots, as in lentigo, or diffuse or in large patches, 
as in chloasma. Acquired deficiency is seen mixed with excess 
in leukodermia, and as a symptomatic condition in morphea 
and other diseases. It is a sequel of many eruptions, of which 
most syphilids and lichen planus afford striking examples. 

In all the above cases the excess of pigment is only an exag- 
geration of a normal process, and is derived from the coloring 
matter of the blood. Pigmentation of the skin may also be 
produced by matter foreign to the normal condition of the 
blood, such as bile, nitrate of silver, arsenic, picric acid, etc., 
or by coloring matter rubbed into the skin, as in tattooing, 
chrysarobin applications, etc. 

Pathology. — We still know very little of the mode in which 
general pigmentation of the skin is produced. The study of 
Addison's disease .has, however, made it highly probable that 
whenever the abdominal sympathetic, especially the solar 
plexus, is irritated, general pigmentation is likely to ensue, but 
how or why this is brought about is not clear. With regard 
to local pigmentation from irritants, or as a sequela of skin 
eruptions, it is a direct consequence of hyperemia, active or 
passive, and the exudation or extravasation of blood-coloring 
matter. 

There are two pigments of the skin, Melanin, or true brown- 
ish-black, finely granular epithelial pigment; and hemosiderin 
(Neumann), a golden yellow iron containing blood pigment. 

According to Ehrmann's * studies, the first stage in the em- 

*" Das melanotische Pigment, und die Pigment bildenden Zellen des 
Menschen und der Wirbelthiere in ihrer Entwickelung nebst Bemerkun- 

655 



656 DISEASES OF THE SKIN. 

bryo is the production of a special cell, which he calls a melano- 
blast, by the separation of a cell from the mesoderm which, 
lying between the meso- and ecto-derm, forms pigment granules 
within itself. No other cell can change into a melanoblast which 
perpetuates itself throughout the life of the organism. It is 
neither an epithelial nor a connective tissue cell, forms its own 
pigment from hemoglobin, and carries it itself along its anas- 
tomosing processes. Melanin lying outside cells represents dis- 
integrated melanoblasts and all other free-lying pigment hem- 
atin detritus. 

As is well known the pigment is deposited in the rete muco- 
sum, and almost exclusively in the lowest layers, but it is still 
a matter of dispute as to how it gets there. According to Ehr- 
mann's older observations, chiefly on frogs, in 1884 and 1886, 
pigment may, however, often be seen in the upper layers of 
the corium as well, on its way from the vessels to the rete, 
where it is deposited in the deeper layers, the cells of which, at 
least in frogs, possess ameboid prolongations, and also in the 
corium there are peculiar movable cells, which send branches 
between the epidermal cells. It is by these protoplasmic chan- 
nels that the pigment is transferred from the corium to the 
deeper layers of the rete, and thence to the higher layers of 
the rete cells. 

Unna * doubts the existence of these special cells, admitting 
the presence of pigmented connective tissue cells. He thinks 
the supposed branches are simply lymph channels, and that the 
pigment is conveyed by them into the lymph stream, first to 
the spaces between the cells and then within them, the pigment 
being especially abundant at the distal pole of the nucleus; thus, 
he agrees that the pigment is derived from the blood, and is 
conveyed from the cutis. 

Audry and others deny the presence of pigment below the 

gen iiber Blutbildung und Haarwechsel," 1896, Th. G. Fischer & Co., 
Cassel, twelve colored plates. 

* This process can be traced in amphibia because they possess a special 
layer of these pigmented, mobile connective tissue cells, and it was ob- 
served that where the epidermis was most pigmented, the connective 
tissue cells immediately beneath were almost pigmentless, and hence it 
is evident that they had transferred their pigment to the rete cells. Unna 
disputes the value of arguments founded on observations of frogs for the 
human subject. 



ANOMALIES OF PIGMENTATION. 657 

basal layer of the rete, and Kromayer thinks the chromato- 
phores are protoplasmic processes from epithelial cells. Audry 
considers that the pigment from the blood reaches the epi- 
dermis, where it is partly built up. Thence it is not reabsorbed, 
but transferred by wandering cells which partly pass into the 
lymph spaces, partly remain in interstices of connective tissue 
vessels, where they become fixed stellate cells. All the above 
observers conclude that the pigment is conveyed to and merely 
deposited in the basal layer of the rete, but another theory, put 
forward by Kaposi, and later by Post, is that it is actually 
secreted by it. 

Few accept Jarisch's view that the pigment is formed by 
metabolism of epidermis cells by regressive metamorphosis, and 
travels to and from the corium by lymph channels. 

Post's investigations led him to the following conclusions: 

1. The pigment of the epidermis arises in the protoplasm of 
the epidermal cells in the form of minute rods. 

2. Branched pigment cells are developed in the epidermis 
from ordinary epithelial cells, and convey pigment to the hair 
and feathers. 

3. Where these branched cells appear in the epidermis, pig- 
mented connective tissue cells often fail. 

4. The function of the basal rete cells is to form pigment. 

5. Pigment may find its way from the epidermis to the 
corium. 

6. Pigment may occur in the corium without pigmentation of 
the corresponding epidermis. 

7. Pigment arises as a result of a special metabolic product 
of the skin, according to race, local structure, and irritation in 
ordinary and branched epithelial cells and connective tissue cells. 

The connective tissue pigmented cells regulate metabolism 
by dealing with superfluous pigment-forming substances. The 
epidermic branched cells, by their energetic pigment formation, 
replace the connective tissue pigment cells, and convey pig- 
ment to the horny cells of epidermal structures. 

According to Post: 

1. Lentigines are a normal type of hyper-pigmentation in a 
small area. 

2. Addison's disease is a diffuse normal hyper-pigmentation. 

3. Pigmentary nevi show abnormal formation of pigment in 
42 



658 DISEASES OF THE SKIN. 

both epidermis and connective tissue in addition to normal 
hyper-pigmentation of the epidermis. 

Melanotic growths may lead to abnormal pigment formation 
in the neighboring epidermis and even in mucous membranes. 
He does not believe in the conveyance by special cells of pig- 
ment derived from hemoglobin. 

Ehrmann explains the mechanism of vitiligo or leukoderma 
as follows: 

While pigment is duly formed in the corium, owing to an 
absence of the transferring cells it cannot reach the rete, but 
in albinism there is a total absence of pigment-forming cells. 
In vitiligo the untransferred pigment in the corium is partly 
reabsorbed, partly transferred to the adjoining normal skin; 
hence the excess of pigmentation that is generally observed on 
the borders of the white patch. What leads to the atrophy of 
these pigment-transferring cells, and why in progressive leuko- 
derma an increase of pigment precedes its disappearance, is not 
explained. 

The pigmentation of hair is closely analogous. The pigment- 
forming cells are situated in the hair papilla, i. c, deep in the 
corium; connected with these, branched cells, similar to those 
in the rete, are situated in the hair root, and send their pro- 
longations between the epidermis cells of the hair, and the pig- 
ment is by their means transferred to the upper part of the hair. 
In addition to the pigment cells of the papillae there are others 
in the matrix, and these two sets are connected by intermediate 
ones. Canities, or white hair, is practically leukoderma of the 
hair, and, as in that disease, while the pigment cells of the papilla 
are still present in all cases except in senile atrophy, both the 
transferring cells and also the pigment-forming cells of the root 
are absent, and hence it would appear that here also it is not 
the formation of pigment that is defective, but the means of 
transmission. According to Riehl the variations in color of the 
human hair are dependent not on the different amount of air 
in the hair, or the color of the individual hair cells, or the 
amount of sebum on the surface, but on the varying quantity of 
pigment in the horny substance of the hair. 

Unna * endeavors to classify pigmentations according to 
whether they consist of melanin or hemosiderin. Although 
* " Histopathology,'* with good bibliography, p. 975. 



LENTIGO. 659 

assuming more knowledge than we actually possess, the attempt 
is ingenious. 

Melanosis includes: 

Actinic melanosis. \ Epheiis. 

Pinta cerulea. 

Pigmentary syphilid. 
Addison's disease. 
Arsenical pigmentation. 



/3. Toxic melanosis. 



Macula cerulea from pediculus pubis. 
y. Reflex melanosis Chloasma. 

In all these the iron reaction can never be obtained. 

{ Post-hemorrhagic pigmentations. 
I Various chronic stagnation pigmen- 
Hemosiderosis includes : \ tations. 

I Sarcomatous pigmentations. 

(_ Ulcerations and scar pigmentations. 

All these give the iron reaction. 

LENTIGO. 

Deriv. — Lens, a. lentil. 

Synonyms. — Freckles; Ephelids; Fr., Lentigo; 
Ger., Sommersprosse. 

Definition. — Circumscribed spots or patches of pigment of 
small size, which occur chiefly on the face and hands. 

Symptoms. — This well-known affection begins usually in the 
second decade of life, and consists of spots of pigment, round- 
ish or irregular in shape, pin's head to split pea in size, and 
yellowish to yellowish-brown or umber, sepia black, and occa- 
sionally greenish, in color. They occur chiefly on the face, 
especially at the root of the nose and adjoining part of the 
cheeks, on the back of the hands, and less frequently on cov- 
ered parts, such as the forearms and arms near the elbow, the 
back, buttocks, and penis. * There may be only a moderate 
number about the nose, or the whole face and neck may be 
thickly peppered with them, especially common in red-haired 

* A case of a man with lentigines in all these positions attended at 
U.C.H for a chronic dermatitis herpetiformis; he was fair and reddish- 
haired. Hebra figures such a case in his Atlas, Lief viii. , Plate V., affect- 
ing the buttocks and penis. 



660 DISEASES OF THE SKIN. 

persons, and in bad cases large, dark, irregular patches are 
mixed up with the more numerous small kind, and the affection 
is then very conspicuous and disfiguring. 

Sangster showed a young man to the Dermatological So- 
ciety in 1893 who had extensive freckles and pigment patches 
of a square inch in size all over the body, buttocks, and thighs, 
nearly to the knees; the face was free. It began in the first or 
second year of life. A brother had the same, and his mother, 
who died of cancer, was similarly pigmented on the upper part 
of the chest. 

A less common form is where a dozen or two discrete, deep- 
tinted, pea-sized spots are scattered irregularly over the face, 
without any of the smaller ones interspersed. Freckles gen- 
erally appear first in the summer, sometimes suddenly, and are 
always most conspicuous at that season, while in the dark days 
of winter they fade away more or less, reappearing in the sunny 
season. 

When similar spots, whether congenital or acquired, occur 
either on covered or uncovered parts independent of seasonal 
change, they are popularly called " cold freckles," and some 
authors reserve the term " lentigo " for these, and give the 
small ones only, which are most conspicuous in summer, the 
title of ephelids; but the distinction is futile. 

In a patient of mine, a young lady, set. twenty-six, pigment 
spots from a millet to a hemp seed in size commenced seven 
years before on the thighs, and had continued to increase in 
numbers until there were many scores, chiefly on the thighs and 
front of the trunk; some months before I saw her a few ap- 
peared on the sides of the face. There were anemia and con- 
stipation, and she held a post of anxious responsibility, but there 
was no other traceable cause. 

In a gentleman,* set. thirtv-nine, with locomotor ataxv of 
specific origin, there was a pigment patch on the right cheek a 
centimeter square, which began the size of a pin's head five 
years before. It had been removed four or five times by elec- 
trolysis and ethylate of sodium, and had not returned for seven 
or eight months until after the last removal, when it reappeared 
in two months. He had three other hemp-seed spots, almost 
black, two of them on the left foot. Possibly this is an early 
*Mr. D., Private Notes, vol. G.,p. 100. 



LENTIGO. 66 1 

case of lentigo senilis. Similar spots are sometimes seen * on 
the lips and oral mucous membranes. Hutchinson f has re- 
corded the case of two girls, twins, brunettes, and quite healthy, 
in whom freckle-like pigment spots developed round the mouth 
at the age of three, and at the age of nine there was dense 
freckling on the lower lip, including the red part and mucous 
membrane, and slight pigmentation on the upper lip. Both girls 
had exactly the same distribution; two years later it was un- 
altered. Balzer J had a case in which it was not only round the 
mouth, but on the eyelids, back of the hands, and on the fore- 
arms. It came after typhoid. 

Lentiginous pigmentation is sometimes unilateral. Such a 
case is depicted in my Atlas, § occupying a part of the domain of 
the supra-orbital nerve and second division of the fifth nerve. 
Robinson, Fordyce, Fox, and Bronson of New York have had 
similar cases, and one was published by Fere in France. || 

In a lady of forty lentigines and soft pigmented fibromata, 
about one-twelfth to one-eighth of an inch, developed from 
telangiectases. I saw one spot, half pigmented and half 
telangiectic. 

As a symptomatic condition it may be seen as a prominent 
feature of atrophodermia or xerodermia pigmentosa, beginning 
then in the first or second year of life, while it also forms a part 
of another form of atrophy of the skin, that of old age, occur- 
ring then on covered parts. I have also seen it following 
eczema in senile persons. 

Pigmented moles sometimes commence apparently as lentigo, 
and subsequently become prominent and assume the mole char- 

* Knowsley Sibley's case, Clinical Journal, August 6, 1896, p. 231. 

f Hutchinson's small Atlas, Plate CXLI., and Archives, vol. vii. (1896), 
p. 290. 

% Annates de Derm, et de Syph., vol. viii. (1897), p. 1106. 

§ Plate LIL, Fig. 2. The patient was a girl of six and a half. The 
pigmentation began when she was six months old, the size of a pea, and 
gradually increased until she was four and a half years old, and had since 
remained stationary. 

\Nouvelle Iconographie de la Salpetriere, vol. i., No. 3, 1888. The 
patient was an epileptic. Fordyce and Bronson's cases had infantile 
paralysis. 

Robinson's was the case of a woman, set. twenty-nine, in whom lentigi- 
nous spots not larger than a pin's point began in childhood, and devel- 
oped into a patch occupying one side of the forehead only. 



662 DISEASES OF THE SKIN, 

acter. A young girl and her brother were brought to me with 
lentigo because their father and aunt had numerous pigmented 
moles which had started as simple pigment spots. 

Lentigo Senilis. Lentigo maligna, or senile freckles, has been 
described by Hutchinson * as occurring in old people. It com- 
mences as small irregular pigment spots, from sepia to black 
in color, on the eyelids or orbital region, and they coalesce into 
a patch or patches affecting even the palpebral conjunctiva, and 
on these eventually, perhaps after many years, epithelioma is 
very likely to supervene. He has had six cases. I have seen 
several such spots and patches before and two after the epitheli- 
oma period, not only about the orbit, but on the forehead and 
cheek; and Dubreuilh f has had four cases, in one of which 
sarcoma had supervened. 

Etiology. — This affection is rare before eight years old, but 
Wilson says it is sometimes congenital, appearing soon after 
birth and continuing throughout life, and I have also seen J 
cases in which this account of it was given ; but this form should 
be classed with pigmentary nevi, and often develops into moles. 
The ordinary variety often disappears as old age approaches. 
Both sexes are equally liable to it, but it is much more common 
in those of fair complexion, and red-haired people are seldom 
free. At the same time freckles may be seen in dark-complex- 
ioned individuals, and even in mulattoes. 

The chief exciting cause, by almost universal consent, is sun- 
light, direct or diffuse; hence their prevalence in summer, per- 
haps because pigment activity generally is greatest in strong 
sunlight. 

Hebra rejects the sun theory, because they may occur in 
covered parts, but probably there are other causes also, which 
we are unable to trace, and it may not be essential that the 
sun's rays fall directly on the affected region. Defective nutri- 
tion is a cause of symptomatic lentigo, and it is seen in associa- 
tion with anemia, constipation, and lesions of the abdominal 
viscera. 

* Hutchinson's Archives, vol. v. (1894), p. 257, Plate CVI., and in 
smaller Atlas. 

I Dubreuilh, Annates de Derm, et de Syfth., vol. v, (1894), p. 1092. 
\ Miss H., Private Notes, vol. ii. p. 264. 



CHLOASMA. 663 

Pathology. — Lentigo differs from other pigmentation only in 
being situated in a circumscribed portion of the rete. 

Anatomy.— Moritz Cohn* of Hamburg has investigated the anatomy of 
ephelids, lentigines, and naevi pigmentosi, and finds that in ephelids 
the cutis and vessels are normal, the only change being the presence of 
pigment in the basal layer of the epidermis, while in lentigines and nevi 
the pigment is always in all the layers of the epidermis and in the cutis, 
down to the subpapillary layer, and that the vessels of the cutis are 
always hyperplastic and the endothelial nuclei swollen. 

It is evident that he uses the term lentigines for those congenital pig- 
ment spots which I have already pointed out are really pigmentary nevi. 

Treatment. — This will be given under Chloasma. 



CHLOASMA. 

Deriv. — x^ oa ^°°y to be pale green. 

Definition. — Chloasma is a generic term for both the irregu- 
larly shaped and sized patches of yellowish, brownish, or black- 
ish pigmentation which occur chiefly upon the face, and for the 
more diffuse discolorations which may occur anywhere or 
everywhere upon the body. 

Symptoms. — The only change in the skin is in the color of it. 
When in patches their borders are fairly well defined. Though 
oftentimes round or oval, they are infinitely varied in size and 
shape, and while the tint is most commonly fawn-colored, 
yellowish-brown, or brown, it may deepen into bronze or black 
(melanodermia) . 

In the diffuse form the borders generally merge impercepti- 
bly into the normal skin, and although the pigmentation may be 
very extensive, even to universality, certain parts of the body, 
chiefly those that are normally pigmented, are generally deeper 
in tint than the rest, viz., the axillae, nipples, umbilicus, pubes, 
and genitalia. 

Etiology. — The idiopathic form is generally the consequence 
of some external irritation, and is generally localized to the part 
irritated. It may, however, arise without apparent cause. The 
principal causes are: 

Counter-irritants, such as sinapisms, f vesicants, etc., which 

* Monatsh. f. ft. Derm., vol. xii. (1819), p. 119, illustrated. 

f Dubreuilh published a case which extended beyond the site of the 
sinapism, and went all around the body. — Ann. de Derm, et de Syfth., 
vol. ii. (1891) p. 76. 



664 DISEASES OF THE SKIN. 

may be followed by pigmentation, generally of a brownish hue, 
on their site of application. I have also seen deep pigmentation 
follow an abrasion, a phenomenon of the same class, while the 
heat of the sun produces the well-known sunburn, and artificial 
heat discoloration of the part exposed, sometimes in rings (see 
Erythema ab igne), as may be seen on the legs of stokers or 
others subjected to similar influences. Friction, pressure, or 
scratching, if long continued, also produces pigmentation, 
which may be both extensive and permanent. This is seen in 
its highest degree in severely itching diseases, like prurigo and 
phthiriasis, as in tramps * and aged people, constituting the 
pityriasis nigra of Willan. In two cases recorded by Thi- 
bierge, and in another by Chatin, the oral mucous mem- 
brane was also stained. A case f of permanent pigmenta- 
tion in a young man, following exposure to great cold 
in Sweden, came under my notice some years ago. (See 
Keratosis nigricans.) Lees showed a child, set. eleven, at 
the Dermatological Society, in whom, when six months 
old, small red spots appeared, and left pigmented areas, 
which increased in size, the longest being two inches by one; 
they were still increasing in number and size, and were scat- 
tered over the neck, trunk, and limbs. Gautier J records a case 
of a boy of six in whom pigmented patches from sepia to 
almost black began to form at the age of two years, and were 
distributed all over the body; precocious maturity of the genital 
organs preceded and accompanied the pigmentation, but the 
hair of the head was ill-developed. 

In a case shown by Bunch to the Dermatological Society a 
youth of eighteen, six weeks after a fall on his left side, noticed 

* Greenhow published cases of this under the name of " Vagabond's 
Disease simulating Morbus Addisonii," in Clin. Soc. Trans., vol. ix. 
Hebra's Atlas, Lief 5, Plate VIII., shows sepia pigmentation; while in 
Alibert's Quarto Edition of 1832 there is a Plate at p. 526, where the skin 
was quite black where pediculi were most numerous. The history is at 
p. 746. Audry has examined the skin histologically; he found abundant 
pigment in the cylindrical layer of the rete, and also uniformly spread in 
small quantity throughout the rete. There was chronic inflammation in 
the corium and pigment in blocks and grains in various parts of \X..—Jour. 
Mai. Cutanees, vol. xiii. (1901), p. 213. 

f Clin. Soc. Trans., vol. xiv. p. 152. A somewhat similar case, also 
following exposure to cold, is recorded by Carrington in the same volume. 

% Abs. Ann. de Derm, et de Syph., vol. i., 1890. 



CHLOASMA. 665 

a small patch of pigmentation over the site of injury. It grew 
for two and a half years, and when seen three years after the 
accident it was 31-2 by 2 1-2 inches and of a brown color. 

Symptomatic Chloasma may be a sequel or concomitant of 
various skin eruptions, may be consequent on, or sympathetic 
with, phvsiological or pathological conditions of the uterus, or 
due to cachexia. 

As a sequel to various lesions of the skin, independent of 
pruritus, it follows syphilids, varying from fawn to dark brown, 
and often of long duration; lichen planus, in which it is very 
deep, almost black sometimes, and also lasting long; after urti- 
caria in exceptional cases: after erythema marginatum and other 
forms of erythema exudativum, where it is often marked, but 
not, as a rule, very persistent, and after repeated exposure to 
the Rontgen rays. 

As a concomitant symptom, it may be seen in senile atrophy 
of the skin, in which it is diffuse; in urticaria pigmentosa; in 
sclerodermia. both diffuse and circumscribed, in which it is 
generally in streaks or patches ; in fibroma, in which it is in large 
blotches on the trunk, but on the face it may be diffuse; in the 
pigmentary syphilid, where it is limited to the neck and asso- 
ciated with leukodermia; and in rare instances with psoriasis and 
pityriasis rubra. Below the knee pigmentation is easily pro- 
duced by slight causes, especially when there are varicose 
veins. 

After a slight injury or inflammation blood-coloring matter is 
effused into the tissues, either by transudation or by capillary 
extravasation. This is seen in its most extreme form where 
eczema has supervened on bad varicose veins, leaving the tissues 
round the ankle infiltrated and almost black. In a very few 
cases pigmentation on the face and chest resembling tinea ver- 
sicolor has been observed where the demodex folliculorum has 
been very abundant (see Demodex). 

The orange and cafe-au-lait patches so often seen in the 
lower part of the legs are due to capillary rupture, doubtless 
consequent on an antecedent lesion, morbid or traumatic, 
though it is often so trivial as to escape notice. Perhaps a simi- 
lar explanation accounts for the rare cases in which appar- 



666 DISEASES OF THE SKIN. 

ently causeless patches of pigment have appeared on the front 
of the legs, often quite symmetrically. McMurray of Sydney 
sent me photographs of such a case in a boy of ten; they had 
been present two years. Hutchinson * records a similar case 
in a boy of thirteen; they faded in about four years from the 
onset. Two cases have been shown at the Dermatological So- 
ciety of London by S. Mackenzie and Perry, also in a boy, 
which suggested that the condition was of similar origin to cafe- 
au-lait patches. 

Chloasma Uterinum may be a physiological or sympathetic 
pigmentary disturbance. It is seen on the linea alba, the nip- 
ples, cheeks, and forehead, of pregnant women until after par- 
turition, and occurs in others also, who suffer from uterine irri- 
tation. The color is a dirty yellow or brownish tint, defined or 
shading into the surrounding skin. Its most common and char- 
acteristic position is on the forehead, where it forms a continu- 
ous or interrupted patch, with irregular borders, between the 
hair and eyebrows, expanding at the temples, but it may be 
almost all over the face, and in rare instances on the trunk 
and limbs. It may occur at any time from puberty to the 
climacteric, but in single women is rare before thirty. A singu- 
lar variety is recorded by Swayne in a woman, in whom during 
the last three months of three successive pregnancies the face, 
arms, hands, and legs were spotted like a leopard, and remained 
so until after her confinement. In a lady,f aet. thirty, sent to 
me by Dr. Saltzmann, the color became deeper with each suc- 
cessive pregnancy, until the whole face, neck, and bend of the 
elbow were bronzed as if she had been exposed to a tropical 
sun, while there were patches of a darker, almost black hue on 
the forehead, temples, and round the mouth. In a woman, set. 
forty-five, under my colleague, Sir John Williams, for ovarian 
tumor, four pigment spots, from one-third to three-quarters 
of an inch across, developed slowly and symmetrically just 
above the umbilicus. Kaposi J knew a lady with a pigmented 
mole two inches square on the side of the neck, which became 

* Archives, vol. iv. (1893). S. Mackenzie, Brit. Jour. Derm., vol. x. 
(1898), p. 416. Perry, loc. cit., vol. xiii. (1901), p. 54. This case had 
punctiform telangiectases like Schomberg's spreading case in the same 
volume, p. 1. 

f Mrs. H., vol. C , p. 27. 

X Loc. cit., Berlin International Congress. 



CHLOASMA. 667 

quite black at each pregnancy, and was the first recognizable 
sign of her condition. Boxall had a case in which the cicatrix 
of an ovariotomy done during pregnancy became pigmented 
a few weeks after the operation. 

A similar pigmentation may be occasionally met with in dis- 
orders of other abdominal viscera. Thus, in abdominal tu- 
berculosis, Gueneau de Mussy has noted a pigmentation of the 
face like that of chloasma uterinum; sometimes, in addition to 
the nose and cheeks, the backs of the hands and even other parts 
may be discolored almost like Addison's disease. He has also 
seen it in four cases of cirrhosis with ascites, and in one of 
cancer of the stomach. I have also seen it in a lady who suf- 
fered from extreme chronic constipation, but with no uterine 
symptoms. Cases occur sometimes in quite young persons in 
which the cause is untraceable. In a healthy married woman of 
thirty-three a pigment spot first appeared on the upper lip and 
spread over the inner side of the cheeks, orbits, and forehead, 
like the usual chloasma uterinum. 

In Graves' * disease, pigmentation, either frecklelike or 
patchy, is not uncommon about the orbits and in those parts of 
the body where there is normally some pigment; it may be uni- 
versal or in the form of leuko- and melano-dermia (see also 
p. 67). 

Bronze Diabetes. In 1882 Hanriot and Chauffard f were the 
first to describe general bronzing of the skin in association with 
diabetes mellitus and hypertrophic cirrhosis of the liver, which 
they called bronze diabetes. Osier $ and others have shown 
since that the diabetes is a late epiphenomenon, and that the 
disease is a hemo-chromatosis, characterized by accumulation 
of an iron-containing and an iron-free pigment, which set up 
a chronic interstitial inflammation of the liver and pancreas, and 
when a certain grade of inflammation of the pancreas is reached 

* A case is figured by Drummond like leuko- and melano-dermia in Brit. 
Med. Jour., May 16, 1887. See also H. W. G. Mackenzie in Lancet, 
September 13, 1890, pp. 5-46, with many references. 

f A later paper, by Hanriot alone, gives a resume 'to date, and discusses 
the different views as to the pathogeny, Brit. Med Jour., January 25, 
1896, p. 206. 

% Brit. Med. Jour., December 9, 1899. Hypertrophic cirrhosis of liver 
with bronzing. 



668 DISEASES OF THE SKIN. 

diabetes ensues, and is the beginning of the end. It is a special 
disease, and of thirty known cases all have been males. 

Blue or slate-colored pigmentation, indistinguishable from 
argyria in tint, may also be observed in the same connection of 
pigmentary cirrhosis of the liver and pancreas. In a case re- 
corded by Dr. Maude Abbott,* the patient was a woman known 
in the hospital as " Blue Mary," from her slaty color, deepest on 
the exposed parts, face, neck, and hands, but it was general to 
some degree. At her death the liver and kidneys were found 
as described, but very little pigmentation could be seen in the 
skin. A slate-colored case without any history of the ingestion 
of nitrate of silver was shown at the Dermatological Society 
some time ago, by Mitchell Bruce, f and I am now inclined to 
think that the case represented on Plate XXXVIII. of my Atlas 
as " Argyria " may also belong to this class. In both Bruce's 
and my case the men showed no evidence of visceral disease. 
Both had had syphilis. Neither had glycosuria. 

Spender draws attention to the frequency of pigment patches 
in association with rheumatoid arthritis; sometimes it is len- 
tiginous, in others, in large patches. 

Discoloration of the skin is common in many cachectic states. 
Thus in secondary syphilis there is a very characteristic earthy 
hue of the face. In nodular leprosy of Europeans, besides vari- 
ous discolored patches on the body, there is a general bronzing 
or livid brown tint late in the disease, and a fawn or yellow 
color in the early stage. In Addison's disease there is the well- 
known general bronzing of the skin, extending to the mucous 
membranes. In cancer there is a sallow lemon tint. In the case 
of a man suffering from multiple melanotic sarcomata, Wick- 
ham Legge X observed nitrate of silverlike pigmentation on the 
face, neck, and hands, but very little elsewhere. In malaria the 
skin may be of a yellowish or chestnut brown to black color, 
chiefly after long exposure to its influence, but it occurs in an 
extreme and acute development in the pernicious forms, as in 
the " Black disease " of the Garo Hills in Assam. § 

*M. Abbott, Jour. Path, and Bacteriology, vol. vii. (1900), p. 55; abs. 
Brit. Jour. Derm., vol. xiii. (1900), p. 63. 

f Mitchell Bruce, Internat. Atlas of Rare Diseases, Plate XVII. 

\Path. Soc. Trans., vol. xxxv. (1884), p. 367, with colored plate. 

§ Dr. Clark in Indian Medical Gazette, and full abstract in Brit. Med. 
Jour., November 29, 1884. 



CHLOASMA. 669 

Diagnosis. — The diagnosis can seldom offer any difficulty, ex- 
cept as regards the cause of the discoloration, and this can be 
identified by a knowledge of its etiology in general and the 
modifications produced under various circumstances. In a few 
cases pigmentation on the skin may simulate pigmentation in 
it, as is seen in that produced by various pigments by hysterical 
women and malingerers. These can always be washed off with 
a weak solution of chlorinated lime, if not with soap and water. 

The discoloration of chromidrosis can also be washed off with 
spirit of chloroform or ether. 

Various fungi may flourish and produce discoloration on the 
skin, such as that of tinea versicolor, crythrasma, and the Mexican 
disease carafe or mal del Pinto. On scraping off some of the 
skin and placing it under the microscope, as directed under 
parasitic diseases, the spores or mycelium can be readily de- 
tected in these forms. 

Prognosis. — This depends, as a rule, on whether the cause is 
still in activity, and upon the length of time it has been in opera- 
tion. Otherwise transitory pigmentations may become perma- 
nent if the cause be frequently repeated, as in some cases of 
chloasma uterinum. 

Pigmentations that are sequelae or concomitants of eruptions 
and those due to irritation generally fade gradually away, ex- 
cept when on the lower part of the leg, and varicose veins are 
present. 

Treatment. — Careful investigation into the cause must be 
made, and when this is removable by appropriate measures, the 
pigmentation will in many cases slowly disappear. It is chiefly 
for pigmentation on the face or other exposed part that advice 
is sought, especially for lentigines and chloasma uterinum. As- 
suming the cause to have been obviated, local applications may 
be of service, and these are chiefly such as remove the epidermis 
more or less completely. 

Unfortunately the relief is too often only temporary, the pig- 
mentation gradually returning. Corrosive sublimate in from 
half to five grains to the ounce of almond emulsion, dabbed on 
several times a day, is one of the best applications, the strength 
being adapted to the sensitiveness of the patient's skin, and two 
grains is the maximum that should be used until that is ascer- 
tained. Hebra recommends a one per cent, solution of hydrarg. 



670 DISEASES OF THE SKIN. 

perchlorid. to be applied on lint cut to the exact size of the dis- 
coloration, and kept constantly wet with the solution for three 
or four hours (care must be taken to apply blotting paper to 
the edges of the lint, as the solution is apt to get dangerously 
concentrated there), vesication ensues, the raised epidermis is 
cut away, and the raw surface beneath dusted with starch pow- 
der. The remedy is severe and not always permanently suc- 
cessful. Other formulae of this kind are given in the Appendix 
(Lotions, F. 11, 12, 13). 

Citric acid solution 5ss, to Jj, has been successful; acetic acid 
and sulphur made into a paste is suggested by Neumann. 

Pure carbolic acid applied carefully with a match, tincture of 
iodin, nitrate of zinc paste, nitrate of mercury ointment diluted 
one to two, nitrate of zinc ointment, veratria ten or twenty 
grains to the ounce of lard, and a host of others have had advo- 
cates, and testify rather to the unsatisfactory results of treat- 
ment than to their success; carbolic acid is one of the best; it 
turns the skin white and it exfoliates in a few days. 

Salicylic acid is worth trying, applied in the form of paste or 
of Unna's plaster for twenty-four hours, or as a saturated solu- 
tion in alcohol applied continuously and kept constantly wet for 
several hours. Desquamation may thus be obtained without 
going too far, as may happen without great care with strong 
solutions of corrosive sublimate and the like. 

Piffard used peroxid of hydrogen to a melsamic patch, and 
partially removed it, but whether temporarily or permanently 
he did not know. Leloir * obtained permanent success with 
the following treatment: The part was first thoroughly cleansed 
with soft soap and alcohol, then painted with several layers of 
a fifteen per cent, solution of chrysarobin in chloroform, and 
this was then covered with a layer of traumaticin, the applica- 
tions being removed when they began to peel off. He not only 
claims to have cured many forms of chloasma, but even flat or 
slightly rugose pigmentary nevi. Hitherto, however, it has 
not been successful in my hands, and in one case the patient 
thought the discoloration was deepened. 

Brocq recommends that the emplastrum Vigo or emplastrum 
rubrum of Vidal should be applied overnight, and perchlorid 

* " Traitement des Melandermies,' fotir. des Connaissances Medicales y 
July 1, 1886; abs. Ann. de Derm, et de Syftk., vol. vii., p. 561. 



CHLOASMA. 671 

of mercury (a grain to the ounce or more) applied as a lotion 
twice a day. 

Hardaway uses superficial electrolysis for ephelids, the needle 
not being introduced deeper than the epidermis. It is well 
adapted and quite manageable for a few lentiginous spots, and 
I have had excellent results with this plan. 

Hardy says that the sulphur waters of Bareges and Luchon, 
in the form of douches, are very effectual sometimes for large 
chloasmic patches. Harrogate and Strathpeffer waters would 
act in the same way. 

Discoloration from matter foreign to the blood may here be 
described. 

Jaundice, produced by the circulation of bile in the blood, pro- 
duces various tints of yellow up to olive green or even bronze. 
Dr. Seymour Taylor showed a case at the Ophthalmological 
Society in April, 1886, in which the lower lid on the right side 
was permanently, while that on the left side had been tem- 
porarily stained of a dark green color, in a patient who had had 
jaundice eighteen years previously. 

In a case of Cavafy's * leukodermia, preceded by dark gen- 
eral pigmentation, followed an attack of jaundice in a man set. 
twenty-nine. 

The connection of jaundice and xanthoma will be reverted to 
under the latter disease. 

With respect to drugs, the most important discoloration is 
that produced by Nitrate of Silver. This discoloration of the 
skin is known as argyria and was much more frequent before 
silver nitrate was displaced by bromids in the treatment of 
epilepsy. Moritz states that the reduced metal is deposited 
chiefly in the rete, sweat glands, and round the hair-roots, while 
the sebaceous glands escape; in fact, in almost the same posi- 
tion as ordinary pigmentation. Riemer and Neumann state 
that it is found in all parts of the skin, except the lining cells 
of the glands and the cells of the rete, the deposit being great- 
est immediately beneath that layer. It only occurs after very 
prolonged administration. Krahmer says the smallest quantity 
that has induced it is 450 grains, and in Riemer's case 1740 
grains had been taken during twelve months before the first 

* Path. Trans., vol. xxxii. (1881), p. 259. 



672 DISEASES OF THE SKIN. 

traces of argyria appeared. It has also been excited by the 
topical application of the silver salt solution to the throat, con- 
tinued for a long time. I have met with a case* in which the 
blueness did not develop for many years after the topical appli- 
cations had ceased to be made. 

Unfortunately, when once it has shown itself, nothing can 
stop its further development. It is of various bluish-gray, slate, 
leaden, bronze, bluish, or blackish shades of color. It is general 
in distribution, including the visible mucous membranes, but 
more marked on the parts most exposed to light, such as the 
face and hands. For treatment iodid of potassium has been 
recommended, but it has little, if any, effect, as a rule; Duhring 
quotes Yandell to the effect that in two syphilitic patients, by 
the prolonged administration of large doses of the iodid for 
several months, combined with mercurial vapor baths, the de- 
colorization was slowly effected. 

Arsenic may also produce a brownish or bronzy pigmenta- 
tion ; it has been described along with the eruptions produced by 
the drug. The color gradually fades when it is given up, unless 
the administration has been very long, when I have known it 
last for many years. (See Arsenic under Drug Eruptions, p. 

474)- 

The slate-colored or brownish pigmentation left on the site 
of psoriasis patches, when arsenic has been given, has already 
been described under psoriasis. 

Picric acid, in large doses, produces a yellowish color of the 
conjunctiva, of the skin, and of the urine. 

Tattooing. — After the pattern has been pricked out with 
needles, various coloring matters are rubbed in. Generally 
gunpowder, vermilion, indigo, or carbon is employed. Hebra f 
figures a remarkable instance where the whole body was 
elaborately patterned. W. xAnderson showed another such in- 
stance of Burmese tattooing at the Dermatological Society in 
1892, and there was another case of a woman in Barnum's show. 
When small and in a disfiguring position, and the removal is 
desired, excision is the only plan, the particles being too deep 

* Author's Atlas, Plate XXXVIII., Fig. 1. This plate represents the 
color of argyria, but as the history of the case shows, he had not had any 
of the salt for thirty years, and, as stated on page 615, it was probably a 
case of pigmentation from fibrosis of the liver and pancreas. 

f Atlas, Lieferung viii., Tafel x. 



ALBINISM. 673 

for any less radical measures. Ohmann Desmesnil says that by 
retattooing with glycerole of papoid the tissue round the parti- 
ticles is dissolved, and the freed particles may be absorbed by 
the lymphatics or thrown off by the epidermis. This requires 
confirmation. Grains of gunpowder blown into the skin are also 
best treated by excisions carefully planned, so as to include as 
many grains in one cut as possible : if done antiseptically, union 
by first intention may be obtained. I had a most successful 
case of this kind; a year after the operation no trace of the 
incisions could be seen. 

These tattoo marks are sometimes the starting-point of 
cutaneous lesions. Thus Fox * of New York describes and 
figures a tattoo mark of an anchor on the lines of which twenty 
warts had developed. Syphilis and septicemia have been im- 
planted by ignorant or careless operators. 



ALBINISM. 

Deriv. — Albus, white. 

Synonyms. — Albinismus; Congenital leukodermia; Congenital 
leukasmus; Congenital leukopathia; Congenital achromia. 

Symptoms. — Albinism is the congenital absence of pigment in 
the tissues, and may be either universal or partial. Albinos, as 
people with universal albinism are called, are characterized by 
a total absence of coloring matter in the skin, hair, iris, and 
choroid. Their skin is either perfectly white, or pinkish in the 
thinner parts where the blood-vessels are partially visible. The 
riair is fine and soft, with a silky luster, is either perfectly white 
or of a whitish-yellow tint, as a rule, but in a case recorded by 
Folker f it was red. The pupil appears red, and the iris pink, 
owing to the absence of pigment in it and the choroid, allow- 
ing the color of the vessels to show through; and as the retina 
has no protection against excess of light, photophobia is always 
present, and the irides, eyeballs, and lids are in a constant state 
of movement. Sometimes, when viewed obliquely, the iris has 
a pale blue tint, the result of interference of light, and B. Squire 

* Amer. Jour. Cut. and Gen.-Urin. Dis., vol. ii. p. 216. 
\ Lancet, May 31, 1879. 

43 



674 DISEASES OF THE SKIN. 

has recorded a case where the irides were dark blue, and conse- 
quently there was no photophobia. 

As a rule, albinos are weakly both in body and mind, of 
short stature, with a proneness to chest disease, but there are 
many exceptions, a notable one being a late well-known Eng- 
lish statesman. 

Animals and birds are also subject to albinism, e. g., ferrets, 
blackbirds, etc. 

Partial albinism is much more frequent, and of course more 
noticeable in colored races, but is also to be seen in white peo- 
ple. The absence of pigment occurs in irregularly outlined, iso- 
lated patches of various sizes, the borders of which may be well 
or ill denned, according to whether the adjoining skin is nor- 
mally or slightly under-pigmented, but it is never more strongly 
pigmented. They are the antitheses of the flat pigmented moles, 
and, like them, may have a nerve distribution,* but are rarely, 
if ever, symmetrical. Any hairs on the affected areas are also 
white. 

Etiology. — Heredity is the only known cause of the complete 
form, and this in the shape of family prevalence, as where there 
are several children in a family more than one are almost 
sure to be albinos, and Lesser knew of a family where six out 
of seven were so. In some tropical countries, such as Loango, 
Lower Guinea, it is said to be endemic. On the other hand, it 
is exceptional for the parents to be affected; but in a case men- 
tioned by Schlegel \ the grandfather was an albino, and Marey % 
describes the Cape May albinos, in which the mother and father 
" were fair emblems of the African race," and of their children 
three were black and three white, born in the following order: 
two consecutive black boys, two consecutive white girls, one 
black girl, one white boy. 

At a medical meeting in the Leeward Islands in 1892, A. P. 
Boon showed two albino negroes, and the father related that 
his uncle's wife always bore twins, one of which was white and 

* In Hutchinson's Smaller Atlas Plates I. and II. show a remarkable 
case in a Hindoo with hemiplegic distribution like some cases of ichthyosis 
hystrix, in streaks also. In Ziemssen's " Handbook of Skin Diseases," 
p. 447, a case is figured with a white patch on the abdomen. 

f " Ein Beitrag zur naheren Kenntnis der Albinos " (Meiningen, 1824), 
quoted in Ziemssen. 

X Amer. Jour, of Med. Scz., 1839, quoted in Duhring. 



LEUKODERMIA. 



675 



the other black; and another member related that he knew a 
black man who suddenly became quite white. 

Sym * of Edinburgh related the history of a family of seven 
children who were alternately albino and dark. All but the 
seventh were living and in good health, and without mental 
defect. The parents and other relatives were dark. 

LEUKODERMIA. 

Deriv. — XevxoS, white; and 6s pjxa^ the skin. 

Synonyms. — Vitiligo; Acquired leukasmus; Leukopathia or 
Achromia; Piebald-skin. 

Definition. — An acquired disease characterized by the pres- 
ence of symmetrical and progressive white patches with convex 
borders surrounded by increased pigmentation. 

This is a common disease in tropical countries, but rare in 
Europe. Thus Garden met with 1 in 36 cases in India, Kaposi 
placed it at 1 in 500 in Vienna, Erasmus Wilson 1 in 400 in 
private practice in London, MacCall Anderson 1 in 2500, and 
my own figures give 1.5 for hospital and 2 per 1000 for private 
practice. 

Symptoms. — The affection is entirely one of pigment distribu- 
tion. In many, and I believe in all, though it is denied by some 
authors, there is an increased deposition of pigment preceding 
the white patches. These appear as round or oval, occasionally 
irregular spots in the darker area, which slowly enlarge, driving 
the pigment before them, as it were; the part immediately 
beyond the white area, containing more or less excess of pig- 
ment, which is generally of a light brown hue, and offers a 
sharp contrast to the milk-white area within. The white 
patches, either from unequal spreading or from coalescence, 
lose their roundish shape, but the borders are always convex 
and, as a rule, well defined, but occasionally shade off gradu- 
ally. The darker color diminishes from the white area outwards, 
and always merges imperceptibly into the normal skin. 

The penis is often more deeply pigmented than other parts. 

* At the Ophthalmological Society of London, reported in the Lancet 
July 11, 1891. 



676 DISEASES OF THE SKIN, 

In a few cases the pigmentation is very dark. In one of mine, a 
butler who had severe jaundice some years before the leuko- 
dermia, and some kind of liver disorder immediately preceding 
it, there was a blaze of white down the center of the face, while 
the sides were as dark as the skin of a negro. 

The patches may be few or numerous, affect any or all regions 
of the body successively, including the scalp; the hair also 
nearly always turns white in the affected areas, which contrast 
with the pigmented parts and give the surface a maplike 
appearance. The disease takes many years to travel all over the 
body, and there are generally a few pigmented patches left. 
Thus in a girl in whom the disease began when she was nine, 
and was very extensive when I first saw her at ten, the white 
gradually extended at the expense of the pigment until, at the 
age of thirty, it was reduced to a few pigmented spots at the 
elbows. A negro, * in whom it began at fifteen, was quite white 
at sixty, except some pigment spots on the cheeks, ears, and 
forehead. 

In a white person, when it has spread over a whole region, 
the disease may seem to have undergone a spontaneous cure, 
owing to the absence of contrast, but the normal pigment is 
very rarely, if ever, restored. The progress is not always regu- 
lar, and may be arrested for a time. 

It is more conspicuous in summer, probably owing to the 
pigmented part being deeper-colored then, and sometimes this 
excess permanently disappears, and effects an improvement in 
appearance by diminishing the contrast between the light and 
dark part. This progressive form is always fairly symmetrical, 
often strikingly so, but strictly unilateral cases have been ob- 
served, as in the case of a negro shown by Hitchins at Hutchin- 
son's clinic. 

There is no alteration in sensation or secretion, nor is there 
any subjective symptom, though pruritus has occasionally pre- 
ceded the appearance of the spots. 

The thyroid gland has in some cases been enlarged, as in 
goiter and Graves' disease, while in other cases it appears to be 
deficient, but never to the extent of myxedema, and I have never 
heard of its being associated with that disease. In two cases 

*Magruder and Stiles, Medical Record, March 10, 1894, p. 294, illus- 
trated. 



LEUKODERMIA. 677 

reported by Neisser and Rille * respectively, red pin's-head 
papules appeared on the white patches. 

Etiology. — Both sexes are equally liable, but it is rare before 
ten or after thirty. The youngest case that I have met with 
was a girl four years old. The oldest date of onset was in a 
gentleman, aet. thirty-nine, who had lived in Mauritius all his 
life, and his wife also had two small white spots on the same 
side of the neck, which appeared after coming to England. In 
another case it commenced at forty-two. It may also be hered- 
itary; a former student of University College Hospital in- 
formed me that it existed in his sister, mother, and grand- 
mother. 

The disease is certainly more common in the dark races; 
exposure to the sun is thought to be an exciting influence, and 
in one of my cases it supervened after sunstroke; extreme cold 
seems also capable of producing it, and in a case under J. 
Startin, Jr., it came on in Canada after suffering severely from 
the cold. In my experience it is more common in neurotic sub- 
jects, and Lebrun thinks it is always a ground for inquiring 
closely for other neuroses. It has developed after violent 
mental emotion and after a toxic neuritis (Emery), and after 
tuberculin injections (Du Castel). I have seen associated with 
it migraine and retinitis pigmentosa, the patient stating that 
the leukodermia had commenced with defective sight nine years 
previously. In association with other skin affections it has been 
seen in connection with morphea, alopecia areata, f with the 
latter disease fairly often; also with Addison's disease, J and 
Graves' disease, all of them considered to be diseases with a 
neurotic element in them. Not only achromic patches, but true 

* Annates de Derm, et de Syph., vol. vii. (1896), p. 1382, a report of 
Vienna Derm. Soc., and reference to Neisser's case. 

f According to Thibierge, the alopecia associated with leukoderma is 
not the same as alopecia areata, and is persistent. While agreeing with 
the former statement, I do not with the latter, as I have seen the hair 
grow again repeatedly. In my Atlas case the hair fell off completely 
after a fright, and the leukoderma developed seven months later. The 
hair grew again, after some years of treatment, almost all over the scalp. 

\ Vide interesting correspondence between Wilks and Gairdner, in 
which Wilks disputes leukodermia occurring in Addison's disease. Lancet, 
July 28, and August 4, 1900, pp. 246 and 349. Also a case of the combi- 
nation February 17, igoo, p. 453. Also Brit. Jour. Derm., vol. xiii. (1901), 
P- 39- 



678 DISEASES OF THE SKIN. 

leukodermia may occur after psoriasis, as I have seen in one 
case of my own. Depressing influences, especially severe ill- 
ness, such as ague, intermittent fever, scarlatina, and typhoid, 
have preceded the disease in many instances. It has also been 
observed after hysterectomy. Cavafy's case following jaundice 
has already been mentioned. Localized leukodermia has fol- 
lowed compression by an inguinal truss (Hallopeau). 

Pathology. — There are strong grounds for regarding the dis- 
ease as due to an angio- or tropho-neurosis, but how this pro- 
duces it, and why, is not clear. The anatomy of the process has 
been explained under the pathology of pigmentation in general. 
S. Marc finds that there are thinning of the rete and other signs 
of atrophy of the skin and a complete absence of chromato- 
phores. 

Diagnosis. — This will seldom give much difficulty. Its sym- 
metry, progressiveness, and the combination of excess and de- 
ficiency, are characteristic features; in all these points it differs 
from the congenital white patches which are sometimes to be 
observed, and called partial albinism. 

In India the disease is sometimes mistaken for macula- 
anesthetic, or nerve-leprosy, and indeed it is sometimes called 
" white leprosy "; it has, however, nothing in common with true 
lepra, and the pale patches on the skin of the late stage of 
nerve-leprosy may always be distinguished by the more or less 
pronounced anesthesia in the affected areas, while the sensibility 
is never affected in leukodermia.* When the white areas have 
spread over a large part of the body, driving the pigment, so 
to speak, into small islands, the pigmentation becomes the most 
striking feature, and the affection may be mistaken for 
chloasma; the concave border of the pigmented area should sug- 
gest leukodermia, and more attentive observation will then 
reveal the abnormal whiteness of the surrounding skin, and the 
history will clear up any remaining doubt. 

The whiteness often seen in morphea may be distinguished by 
its being accompanied by a change in the texture of the skin, 
which is often parchmentlike, though it may be atrophic, and 
by the other signs of that disease. 

* Barbe relates a case of vitiligo and hysteria following Battey's opera- 
tion in which there was anesthesia in the white areas, but this was prob- 
ably due to the hysteria rather than to the leukodermia. 



LEUKODERMIA. 679 

Prognosis. — It will be gathered from the above description 
that the disease is not a very hopeful one, though spontaneous 
arrest may occur. In course of time improvement may take 
place, either through the excess of pigmentation fading, or by 
a whole area becoming white, and so the contrast is lost; this 
is the probable explanation of reported cures.* A case is re- 
ported by Stelwagon of Philadelphia, in which the whole body 
surface thus became white, and exposure to the sun had no 
effect on it. 

Treatment. — This is highly unsatisfactory; nothing appears 
to have any controlling influence. Duhring recommends 
arsenic, but apparently on theoretical grounds; perhaps, if given 
long enough or in large enough doses, arsenical pigmentation 
might ensue, which would, at all events, be a better match than 
that proposed by Brito, who suggested that argyria should be 
produced. 

General tonics are also recommended, and an effort should 
be made to put the general health of the patient in as vigorous 
a. condition as possible; in this way we may hope to arrest the 
disease, though we can hardly hope to restore the lost pigment. 
In consequence of the defective thyroid noticed in some cases 
I have tried thyroid extract internally, but was unable to see 
any effect, though it was given for some months. Noticke, how- 
ever, in his own case, which began when he was five years old, 
found that at one point the pigment was spontaneously re- 
stored, while the rest remained unaffected. 

Ehrmann relates a case where small pigment spots appeared 
after a time in the leukodermic patches; these Kaposi suggests 
might have been unperceived lentigines, which the contrasting 
whiteness of the disease revealed, but this explanation will not 
hold if leukodermia is produced by the cessation of the pig- 
ment supply. 

Local treatment is directed towards diminishing the contrast 
between the light and dark parts. The excess may be attacked 
in the same way as is recommended in chloasma, while the white 
part may, where it is worth while, as on the face, be slightly 
stained with walnut juice or other pigment. 

* E. g., Balmanno Squire's case, Brit. Med. Jour., April, 1881. 



CLASS VI. 
ATROPHIA— ATROPHIES. 

ATROPHIA CUTIS, OR ATROPHODERMIA. 

True atrophy of the skin may be quantitative or qualitative, 
i. e. y there may be simply diminution in the number and size of its 
component elements, or an alteration of a degenerative char- 
acter of those elements. 

Degenerative Atrophy. — Information is still wanted with re- 
gard to the anatomical distinctions of different qualitative 
atrophies, but there is not necessarily diminution of bulk, and 
there may be actual increase, as in the later stage of morphea, 
where there is thickening from increased connective tissue; but 
at the same time the skin is hardened, yellowish, or whitish and 
waxy-looking, loses its natural lines, and is sometimes puck- 
ered at the borders; in their earliest stage the small white spots 
are examples of the quantitative form. 

Quantitative Atrophies. — In this condition, speaking generally, 
the skin is thin, usually very white, but sometimes pigmented, 
finely wrinkled, and dry; or, when there is contraction of the 
part below, as in the last stage of sclerodermia, stretched, 
smooth, and shining. 

This atrophy may be idiopathic or symptomatic, and each of 
these may be diffuse or circumscribed, and these again may be 
further subdivided. As the terms speak for themselves, all 
these atrophies may be placed in a tabular form, which will 
show their relations to each other without further explanation. 

Atrophoderma Propria. 

f Juvenilis j Pigmentosa 

r Progressive | (Xerodermia) t Albida. 
r Diffusa ^ or in i arge { Congenitalis ( Quantitativa. 
Atrophoder- I patches Senilis 1 Qualitativa. 



mia Idio- 

pathica | Circumscripta i Non-traumatica. 

63o 



( Traumatica. 
(Striae et Maculae) 



XERODERMIA PIGMENTOSA. 681 

Atrophodermia Propria {continued). 

fNeuritica ( Traumatica. 



(Glossy skin) { Non-traumatica. 

Atrophodermia Symptomatica \ f Sclerodermia. 

j Seborrhea. 

LMorborum cutis \ Lupus. 
| Syphilis. 
L Favus, etc. 

The symptomatic atrophies due to other skin diseases are 
described under their primary disease; the others only will be 
given here. 

Two diseases of trophic origin, though not atrophies, are in- 
cluded in this section, viz., perforating ulcer and ainhum. 

XERODERMIA PIGMENTOSA.* 

Synonyms. — Atrophodermia pigmentosa (Crocker); Angioma 
pigmentosum atrophicum (Taylor); Dermatosis Kaposi 
(Vidal); Liodermia essentialis cum melanosi et telangiec- 
tasia (Neisser); Melanosis lenticularis progressiva (Pick). 

This disease is a very rare one, but owing to its striking 
peculiarities it is easily recognized, and there are over a hundred 
cases on record, though the disease has only been known since 
Kaposi f first described it in 1870. The first three cases known 
in England came under my care in 18834 an d two of them are 

* In the first edition of this work I suggested atrophodermia instead of 
xerodermia as more appropriate and less liable to lead to confusion with 
mild ichthyosis ; but although everyone disliked Kaposi's designation, it 
is in a fair way to be generally adopted, and dermatology suffers too much 
from overchristening for me to hold out. 

f Hebra, vol. iii. p. 252. Kaposi's Hand Atlas, Plates 367 to 376, form 
an interesting series. Plates 374 and 375 are noteworthy as they show an 
early stage on the face and hand. Author's Atlas, Plates LVI. and 
LXXV., show the disease in its full development and distribution, and 
are the portraits of the two girls in one family above referred to ; the 
third case, a boy, died in 1895. St. Louis Atlas, Plate XLVII., a case of 
Du Castel, formerly under Tenneson, is interesting, as it shows epitheli- 
omatous ulceration of the nostrils and lip in a child, while there were only 
a few freckles and slight atrophy of the skin to represent the other symp- 
toms. Morrow's Atlas, Plate LXV., produces the well-known casein 
Vidal's valuable monograph. 

X Recorded in Med. Chir. Trans, for 1884, with colored plates and table 
of thirty-four cases. Since then cases have been published in England, 



682 DISEASES OF THE SKIN. 

still alive. The eldest presented all the features in a marked 
degree. A fourth case, a girl, set. ten years, of a mild type, 
came to me in 1897, and a fifth in 1901,* a girl of eight years, 
who, although the usual symptoms were only moderately pro- 
nounced, had an epitheliomatous f fungating growth between 
the brows of six weeks' duration. 

Symptoms. — There are six kinds of lesions present in the great 
majority of cases. Lcntigincs, or frecklelike pigmentation, is 
the most striking and constant of these. This pigmentation is 
generally very densely distributed over the bust and arms. It 
covers the whole surface and especially the lower part of the 
neck to just below the clavicles in front, and to the shoulders 
behind, on the upper limbs, on the extensor aspect. It begins 
about the insertion of the deltoid and extends to the finger-tips, 
and is very thick on the forearms, on the flexor side, the 
boundary slopes down from the back to just above the elbows 
on the forearms. It is less dense on the ulnar side, but the 
rest is thickly covered to the wrists, while the palms are free, or 
nearly so. 

On the lower limbs the thighs are rarely affected, and the 
legs below the knee, both back and front, are but slightly in- 
volved compared to the upper limbs. 

This distribution is very characteristic and constant from the 
first, but in some cases it has fallen short of the above limits. 
Stern and Du Castel record cases in which there were only a 
few scattered freckles along with epitheliomatous tumor forma- 
tion. With regard to extension it is not rare for it to go to 
the third rib, but in Duhring's case it extended to the mammae 
in front, and to the lumbar region behind, and over the whole 
scalp, which is seldom affected, but in one of my cases the tem- 
poral region was involved. 

Ireland, and Scotland. Archambault, in his "These de Bordeaux," 1890, 
collected sixty cases, and gives a good resumd to date. Lesser and Bruhns 
in 1898 collected eighty-seven cases, and there have been fully twenty 
cases since. Nearly a score of cases have been recorded in America, seven 
in one family by Taylor of New York in the Medical Record, March 10, 
1888. 

* This case had been previously under Pringle. 

f Pernet examined the growth, and found epithelioma with horny 
masses, not growing downwards from the epidermis, but apparently from 
the hair follicles. 



XERODERMIA PIGMENTOSA. 683 

Lentisrines have been observed on the back of the foot, on 
the palms, and under the nails. In a recent case of Kaposi's a 
man, set. twenty-five, there was freckling, large and small, all 
over the trunk and buttocks, as well as on the face, upon which 
there were many carcinomata, but in a few cases there may be 
only extensive freckling. 

The color of the pigmentation varies from a pale yellow fawn 
to a deep sepia, and the size from a pin's head to irregularly 
outlined blotches half an inch across, but as time goes on they 
tend to increase in size, and in one of my cases large blotches 
developed on the forearms. 

The second lesion consists of small white atrophic spots inter- 
spersed among the pigment spots on the face. They multiply 
and coalesce into comparatively large cicatricial-looking areas, 
especially about the orbit, and so diminish the pigmentation in 
those regions. The skin is white, shining, finely wrinkled, and 
either smooth or covered with thin white scales. Some contrac- 
tion ensues, and consequently ectropion is produced. Small 
atrophic spots are sometimes left by the spontaneous oblitera- 
tion of telangiectases. 

Or on the larger white atrophic areas, the third lesion, vas- 
cular telangiectases appear. These may be stellate in flat tufts 
or in small tumors, and their bright crimson color on the white 
ground makes them conspicuous. Stellate and other striae may 
also be seen scattered about amongst the pigment spots both 
of the face and limbs; they may be few or very numerous, and 
conspicuous. 

Warts, some very small, others flatly convex, and many re- 
sembling senile warts, are scattered irregularly amongst the 
pigment, and ultimately may form the starting point for new 
growths. Thus in one of my cases a warty growth began on a 
pigment spot in front of the right tragus, it grew to the size of 
a finger-end, and then began to ulcerate, fungate, and ultimately 
formed a pedunculated mass as large as a Tangerine orange; 
its structure was papillomatous (Fig. 33). 

Sooner or later there are superficial ulcerations with yellowish 
or greenish crusts scattered about the face, rarely on the limbs, 
and from these, as well as from the warts, tumors arise which, 
at first papillomatous, eventually become epitheliomatous and 
destroy the life of the patient. Some of these ulcerations are 



684 DISEASES OF THE SKIN. 

the result of pus inoculation from ocular discharges, conjunc- 
tivitis and vascular pterygium being frequently present. 

The healing of the ulcers, whether spontaneously or from 
treatment, produces cicatricial and distorted orifices, such as 
puckering of the mouth, dilated nostrils, and everted lids; hence 
with the scabbed ulcers a resemblance to the disfigurements of 
lupus, for which the disease has been mistaken. 

The development of tumors occurs sometimes quite early in 
the disease, even in cases where the other lesions are slightly 
developed, but more frequently they only appear at an advanced 
stage. 

The character of these neoplasms is diverse, and they may be 
quite innocent at first, and become malignant subsequently, or 
they may be cancerous from the first. This appears to depend 
a good deal on the mode of origin. The tumors growing from 
the warts and ulcers are papillary, and instead of fungating may 
be verrucose. If they are removed or fall off, as they sometimes 
do,* they will not recur in the same place; if they are allowed 
to go on, they become epitheliomatous. Epithelioma may also 
start directly from one or more of the numerous cicatrices, and 
while they are at first local, and can be effectually removed, the 
tendency for others to form increases, until they may be too 
numerous or extensive to deal with, but internal generalization 
is rare. The greater frequency with which the tumors and ulcers 
develop upon the right side of the face is remarkable. Three 
ether minor symptoms remain to be mentioned. There is a 
tine pityriasis of the scalp in many cases, the scales being often 
brownish, while the red of the lips, and for a short distance 
inside, is white mottled with red, but the rest of the oral mucous 
membrane is free as a rule, but the tip of the tongue was once 
affected like the lips. There are granular lids, and the cilia of 
the lower lid are generally lost, and vascular pterygium is often 
present on the conjunctiva. 

Variations. — All the cases resemble each other remarkably, 
but there are some variations, many of which have been men- 
tioned in the description of the symptoms. 

* In my third case a tumor grew in the fingerlike way from the left 
cheek for an inch and a half without ulceration, became strangulated at 
the base, and dropped off, leaving a cicatrix. Vidal and Jameson have 
had similar cases. 



XERODERMIA PIGMENTOSA. 685 

The question of age remains. Several have commenced in 
the first year, three and five months (Rotch's cases) * being the 
earliest recorded, while there is no limit at the other end. Al- 
though the great bulk begin in the second year, there have been 
a few, like Kaposi's and Hutchinson's, which began as young 
adults, and Falcao \ of Lisbon brought forward a remarkable 
series of septua- and octogenarians, in whom, though freckled 
in infancy, no pronounced symptoms occurred until old age. In 
the oldest, set. eighty-nine, the development of active symptoms 
had only commenced five years before. Out of her four chil- 
dren and twelve grandchildren, only one of the latter had 
xerodermia pigmentosa, which began when two years old, but 
all had freckles. The chief differences in the aged were that 
the warty and atrophic elements were conspicuous as compared 
to the pigmentary and telangiectic elements of childhood. 

In a case of Pick's, X a man, set. twenty-one, there was general 
lentiginous pigmentation, except on the face, elbows, and knees. 
The pigmentation was chiefly in the lines of cleavage, and there 
were no other symptoms, although the pigmentation was said 
by the patient and his mother to have been there from birth. 
Probably this case was not really a xerodermia pigmentosa. 

Course. — The disease usually begins in the second year of 
life, but there is some discrepancy as to the mode of commence- 
ment, the accounts being generally derived from patients' 
friends. Brayton of Indianapolis saw a case which began in the 
sixth month of life, with small white atrophic spots upon the 
face; eleven months later the white spots had increased in size 
and number and a few brown pigment spots had appeared. 
There was general erythematous redness of the face and hands 
six weeks later, and in three months more, in July, disfiguring 
pigmentation followed, and some of the atrophic spots were a 
quarter of an inch across. In other cases freckles are said to 
have been the first lesions. In Rotch's case brown spots ap- 
peared on the face and arms at three months, then the telan- 
giectases, and then the white atrophic spots, as shown under 

*T. M. Rotch, Archives of Pedriatrics, vol. xv. (1898), p. 881. 

f Trans. Third Internat. Co?ig. of Derm., London, 1896, p. 280. Matz- 
enauer has had a female case of sixty-six. 

\ Melanosis lenticularis. Neumann's " Festschrift," p. 1002, Plate 
XXXIII., colored. 



686 DISEASES OF THE SKIN. 

" Lentigines " (p. 661); these may develop from telangiectases. 
This latter is not unlikely, as atrophic scarring may spontane- 
ously develop in and obliterate nevoid telangiectases. In my 
fourth case the mother said that, when one year old, every fort- 
night she had attacks of a red rash on the face, followed by 
cracking and peeling; freckles appeared at eighteen months. 
Kaposi figures an early stage with erythematous redness 
of the center of the face and orbits and the back of the hands, 
with white atrophy interspersed, and a few freckles on the 
forehead and sides of the face, therefore like Brayton's case 
at eighteen months old. In Bronson's case when only four 
months old the mother noticed a disposition to redness across 
the bridge of the nose and beneath the eyes. After a slight 
exposure to the sun the face would be swollen and red for 
several days, and sometimes blisters were formed, once an 
acute vesicular outbreak occurred, and at five years old Bowen 
removed an epithelioma from the eyelid. 

In Tenneson's and Danseaux's case at nine months old little 
red spots the size of a sixpence appeared on the cheeks. For 
several years these spots disappeared in winter and reappeared 
in the spring. Gradually the redness became persistent, the 
thinned skin began to crack with serous exudation, then pig- 
ment spots appeared on the face and neck, and the skin became 
parchmentlike and xerodermic. 

At all events the freckling, telangiectases, and white atrophy 
are the earliest and most constant symptoms. The superficial 
ulcerations do not begin for some years, are probably caused 
by the eye discharges, and are extended by auto-inoculation. 

Etiology. — Congenital predisposition is the only known cause, 
though probably some other factor, as an exciting element, is 
required. 

Sex. — The number of males and females is about equal. In 
the 52 cases collected by Elsenberg, 27 were females and 25 
males. It is not hereditary,* but shows a family prevalence,f 
and has then a tendency to select one sex. Twenty-six cases 
occurred in 9 families, and in 7 it affected one sex only. In 
Ruder's series, in a family of 8 boys and 5 girls, 7 boys were 

*Falcao's case, where a granddaughter was affected, is the only ex- 
ception I know of. 

f Two of Taylor's cases were cousins of three other cases. 



XERODERMIA PIGMENTOSA. 687 

affected and the rest of the family were free. Kaposi, Taylor, 
and myself have had exceptions to this. 

Age. — Nearly all the cases begin in the first or second year, 
the youngest being five months,' the oldest eighty-nine years 
(Falcao's),*but the senile cases are very few. It thus resembles 
ichthyosis and prurigo in not appearing until some time after 
birth. 

Hygiene has not been in fault, as many of the cases were in 
good circumstances, but 

Season appears to have some influence, several having begun 
in spring or summer; and exposure to the sun has been sug- 
gested, and in Eulenberg's case proved to be an exciting cause, 
but it does not account for all cases, such as those commencing 
with atrophic spots in early infancy. 

Pathology. — The most feasible explanation is that the disease 
is an atrophic degeneration of the skin, dependent upon a pri- 
mary neurosis, to which there is a congenital predisposition. It 
is noteworthy that all the symptoms may be individually met 
with in the atrophic changes of the skin in old age; it is their 
simultaneous presence in the young that is the characteristic 
of the disease. 

Kaposi's views are probably correct, that the alteration begins 
in the papillary body and epidermis, and spreads from these 
to the dermis, the pigmentation being due to the atrophy, as 
is often seen in other atrophies. Perhaps the vessels are the 
first affected, and besides the above changes, determine the 
formation of telangiectases by collateral dilatation. 

According to Unna the warty growths are formed by the 
accumulation of irregularly stratified and fissured horny layers 
on an irregular granular layer, while the prickle layer sends 
processes into the dermis, which may or may not be connected 
with the glands. 

The tumors are usually described as epitheliomatous, but in 
my case were distinctly papillomatous and not malignant for 
many years, when a single epithelioma formed in a cicatrix and 
was removed without recurrence. Melanotic sarcoma (so 

* Some doubt has been thrown on the diagnosis of Falcao's cases, of 
which four were octogenarians, but Matzeuauer's was sixty-six, and 
Herxheimer and Hildebrand's seventy, and there are a few others which 
approach these ages. 



688 DISEASES OF THE SKIN. 

called) has been met with; probably it was melano-carcinoma. 
So many other varieties of new growth have been described as 
to make one suspect that the personal equation influences the 
christening.* Kreibich f examined growths from three cases 
of Kaposi's, and came to the conclusion that they belonged to 
medullary cancers, in which the basal layer is preserved, and not 
to the horny cancers. 

Anatomy.— I have examined a piece of skin from the upper arm, con- 
taining the commencement of a small wart from the eldest girl described 
above, and a piece from the forearm of the boy containing a small telan- 
giectasis; also the large tumor and a smaller one, and an ulcer which was 
beginning to fungate, all from the girl. 

The results, briefly stated, were: The large tumor was substantially a 
papilloma, consisting of a large quantity of granulation tissue, with 
many spindle cells, tunneled with numerous large vessels. Imbedded 
at intervals amongst this tissue were aggregations of elongated cylin- 
ders, some branched; each was bounded by imperfect palisade epithelium, 
inclosing small epithelial cells, closely but irregularly arranged (Fig. 33). 

The smaller tumor had similar granulation tissue, but the papilloma- 
tous part consisted of digital processes radiating from a common, very 
short pedicle and forming a section of a circle bounded by a thin layer 
of fibrous tissue. The ulcer showed great downgrowth of the interpapil- 
lary processes, with enormous proliferation of the rete itself. Compar- 
ison of this with the tumors made it probable that this proliferation, 
when continued, led in the course of the formation of the tumors, to first, 
separation of these processes from the rest of the rete, perhaps from ulcer- 
ation at the surface, and then, by independent growth and further sepa- 
ration of the several parts, to the numerous elongated cylinders already 
described. 

It is probable that the angio-myxomas of Taylor of New York were of 
this character, and also the " epithleiome verruqueux " of Vidal; but 
Kaposi, in his classical monograph, while figuring a very similar struc- 
ture, shows also typical epitheliomatous nests, and other good observers 
have also testified to their being true epitheliomata. 

There was no evidence whatever of such structure in my case, and the 

* Taylor speaks of " angio-myxomas," and Vidal of " epitheliome verru- 
queux." Others describe them as " sarco-carcinomas." Pollitzer ex- 
amined a tumor removed from my third case in 1890, and described a 
growth of mixed morbid elements, epithelioma predominating, but also, 
he says, sarcoma, myxoma, granuloma, cylindroma, etc. Amer. Jour. 
Cut. and Ven. Dis.. vol. x. (1892), p. 133. The patient did not grow a 
true epithelioma till six years later. See Brit. Jour. Derm., vol. viii. 
(1896), p. 442. In the same volume are a description and colored plate 
of the thirteenth American case. 

f Kreibich, Archiv f. Derm., etc., vol. lvii. (1901), p. 123. 



XERODERMIA PIGMENTOSA. 689 

glands at the base of the pedicle of the larger tumor were healthy, but 
slightly enlarged. It is, however, highly probable that the epitheliom- 
atous structure would have developed in them eventually, if the tumors 
had not been removed. An epithelioma from a cicatrix formed some 
years later. 

In the skin the papillary layer was atrophied and deprived to a great 
extent of vessels; the rete over it was thinned, and formed a slightly wavy 
line. Pigment was imbedded in the cells, and occasionally there was a 
granule in the corium. The wart showed the usual structure, and there 
was a scanty infiltration of round cells below it, but the rest of the corium 
was normal. 

These observations agree with those of Neisser, Vidal, and Leloir. In 
addition to the white atrophied part Neisser found atrophy of the epi- 
dermis, absence of pigment, and a regular line of demarcation between 
the epidermis and the papillary body. Vidal and Leloir found no dis- 
eased nerve fibers, but in the middle of the epidermis were nodules of 
epithelioma, which had, they thought, developed from the cutaneous 
glands. Okamura* examined the blood in three of Kaposi's cases, and 
found that there was an oligocythemia and a rather pronounced leu- 
kocytosis. 

Diagnosis. — The commencement of the disease in early child- 
hood; the formation of frecklelike pigment spots, preceded or 
not by erythema, the development of white atrophy with telan- 
giectases, superficial. ulcers, pigmented warts, and verrucose or 
fungating tumors, and finally epithelioma, together with the pre- 
dominance of the lesions in exposed parts, form a history and 
picture which, viewed as a whole, scarcely admit of error, but 
mistakes have arisen from paying too exclusive regard to one 
or other feature. 

The atrophic stage of some cases of general selcrodermia most 
nearly resembles it, for there may be thinned, white skin, 
with pigment in parts, telangiectases, and tension, so that 
a fold cannot be pinched up without difficulty, but the 
history is very different. Sclerodermia does not begin s*o 
early as most cases of this disease, and commences with 
increase of volume and boardlike hardness and immobility; 
the pigment, telangiectases, and atrophy are of later de- 
velopment. The pigment is not in frecklelike spots; nor are 
the telangiectases so large and conspicuous, being only stellate 
and striate. The position also is paraplegic, and not limited 
to any special regions. In the early stage the red spots have 
been mistaken for measles, the pigment spots for ordinary 
* Archiv f. Derm., etc., vol. li. (1900), p. 87. 
44 



690 



DISEASES OF THE SKIN. 



freckles, the telangiectases for nevi, while in the later stage the 
cicatricial aspect and crusts have led to its being treated for 
lupus. All these errors can be avoided by taking all the points 
into consideration. See also hydroa aestivalis, which has been 
mistaken for xerodermia pigmentosa.* 

Prognosis. — The prognosis is very bad, for although one case 
which began late did not develop tumors for thirty years, in the 
majority they appear in childhood, and when they are malignant 
the patient has but a few years to live, but by following the 




1 

n 

Fig. 33. — A single lobe of the large papillomatous tumor. X 350. 

treatment laid down the evil day may be staved off for many 
years. Two of my first three cases are still alive and fairly well,. 
i. e., nineteen years since they first came under observation. 
Herxheimer's case f was aged seventy, his first malignant 
growth occurring at the age of thirty. He also adduces cases 
to show that the early appearance of malignant tumors does 
not, as Lesser and Bruns aver, show that the disease will run 
a short and malignant course. 

* Graf's case of xerodermia pigmentosa is evidently hydroa aestivalis. 
Abs. Brit. Jour. Derm., vol. ix. (1897), p. 293. 

f K. Herxheimer and Hildebrand, four new cases. Full abs. Brit. Jour y 
Derm., vol. xiii. (1901), p. 66. 



ATROPHODERMIA ALB1DA. 691 

Treatment. — The internal or external means that have yet 
been tried have not been of any avail to cure the disease. 
Arsenic, cod-liver oil, iodid of potassium, and various tonics 
have been given, without any beneficial results. 

Much, however, can be done for the alleviation of the troubles 
consequent upon the ulcers and tumors, and the inflammatory 
condition of the eyes. Diligently bathing the eyes with boric 
acid lotion subdued the conjunctivitis, and relieved the eyes in 
my cases, and by stopping the discharge prevented the forma- 
tion of fresh sores. The recent ulcers were healed with a di- 
luted ammoniated mercury ointment. The older ones were 
scraped w T ith a sharp spoon, dressed with a boric acid ointment, 
and healed satisfactorily. The tumors were excised, and the 
site healed readily. The improvement in appearance and the 
comfort afforded to the patients were very striking, and though, 
no doubt, fresh ulcers would form and tumors develop, if they 
were dealt with at once, it seems probable that the life of the 
patient would be prolonged, and perhaps the development of 
epitheliomata might in some cases be prevented. In the eldest 
of my cases the disease was quiescent for six years, and then 
an epithelioma developed in a cicatrix, but was removed in 1896 
without recurrence up to 1901. Couillaud * claims to have ob- 
tained great amelioration, even with disappearance of a great 
part of the pigment, by intramuscular injections of calomel 
three centigrams, in vaselin and liquid paraffin. 

ATROPHODERMIA ALBIDA. 

Here the condition is stationary. 

As I only know this affection through the description of 
Kaposi, who states that he has seen it repeatedly, and desig- 
nates it as another type of xerodermia, I give it in almost his 
own words. 

Symptoms. — The skin from the middle of the thigh to the sole, 
more rarely from the upper arm to the palm, is strikingly white 
in places, stretched, and difficult to pick up, with the epidermis 
extremely thinned, faintly glistening, wrinkled like gold-beater 
skin, and peeling off in thin, shining flakes. The sensibility is 
very great on the finger-tips, palm, and sole, on account of the 

* Annales de Derm., etc., vol. ix. (1898), p. 443. 



692 DISEASES OF THE SKIN. 

stretching and insufficient epidermis covering, so that the use 
of the hands and feet is interfered with. 

Diagnosis. — The condition remains stationary from the earli- 
est childhood, and from this and the above symptoms need not 
be confused with atrophic sclerodermia. 

Treatment. — Emollient ointments and plasters are useful to 
mitigate the dryness and tension of the epidermis, and the soles 
need protection against pressure in walking. 

Pityriasis alba atrophicans. — Krosing's case,* which he com- 
pares with Jadassohn's, has some analogies with the above dis- 
ease of Kaposi. The patient was a man of forty-four. The 
disease had commenced when he was thirteen as a dry pale, 
scaly patch on the left ankle; it slowly spread upwards, and 
reached to the knee in the course of twenty years, and subse- 
quently to the groin. Scaly desquamation had occurred, but 
there had never been any redness or sign of inflammation. Pari 
passu with the upward spread, the skin, as far up as the knee, 
had become tense and atrophied, covered with small grayish- 
white scales and scaly crusts. On the thigh there was fine 
silver-gray scaling, and the skin was lax; there was a light 
brownish zone at the border. The right limb had been affected 
eight years, beginning at the same place and in the same way, 
and had reached the groin and lower border of glutei. 

Jadassohn's case was universal and had developed in six 
months with marked pruritus. Atrophy of the skin, as in 
Krosing's case, supervened after ten or fifteen years. 

Histologically Krosing found that the disease was not inflam- 
matory, and was due to abnormally rapid cornification of the 
upper epidermal layers, resulting in an atrophied rete, which 
spread both vertically and horizontally and led to tension of 
the skin. 

DIFFUSE IDIOPATHIC ATROPHY. 

Anomalous cases of diffuse atrophy have occasionally been 
reported, such as Wilson's f cases of " General Idiopathic 
Cutaneous Atrophy," Schwimmer's J " Atrophia Cutis Uni- 

* Krosing, Derm. Zeitschr., vol. iii. (1896), p. 57. Jadassohn, Fourth 
Germ. Derm. Congr. Trans., with stereoscopic plates, 
f Wilson, p. 394. 
X Schwimmer, case 20, p. 189. 



DIFFUSE IDIOPATHIC ATROPHY. 693 

versalis," which are probably atrophic general sclerodermia, and 
Atkinson's * " Unilateral Idiopathic Cutaneous Atrophy," which 
was probably morphea. Glax,f Geber,J R. W. Taylor, § and 
others have reported similar cases. Morphea may undoubtedly 
produce atrophic thinning of the skin from the first, and I have 
seen mixed cases in which there was atrophy in one part and 
parchment induration in another, in the same patient. 

Diffuse idiopathic atrophy of the skin apparently primary 
does, however, exist, both congenital and acquired, as in the 
following case by Buchwald | of Breslau. 

The patient was a strong, healthy man, in whom the disease 
began ten years previously, when he was twenty years old, with- 
out apparent cause; it began on the knees and spread mainly 
upwards, soon reaching its present limits, but the change in the 
skin was not completed for a year, since which there had been 
no further alteration, except occasional ulcers on the leg and 
foot in winter. The whole of both thighs, except in the parts 
adjacent to the scrotum, were affected; the skin was quite soft 
and in folds, and when pinched up the folds remained erect; the 
surface was dry, brownish, and desquamating, with dilated 
veins, which, when he stood, made the limbs cyanotic. Micro- 
scopically there was total atrophy of the papillae and fat, partial 
atrophy of the sweat glands and hair-sacs, and the connective 
tissue was swollen and densely infiltrated with cell nuclei. 

Unnal" has had a very similar case in a man of fifty. He 
found atrophy of the rete; disappearance of the papillary body, 

* Richmond and Louisville Medical Journal, December, 1887. 

f Viertelj.f. Derm. u. Syph , Heft i . 1874. 

%Allg. Wiener med. Ztg., No. 35, 1874 

§R. W. Taylor, "Localized Idiopathic Atrophy of the Skin," Amer. 
[our. Cut. and Gen.-Ur. Dis., April, 1893, and Abs. Brit. Jour. Derm., 
vol. vi. (1894), p. 31. 

|| Viertelj. J. Derm. u. Syph.. Heft iv., 1883, with plate. 

■fT (Unna) Neumann's " Festschrift," 1900, p. 9T0. Colored plates, clinical 
and histological, and a classification as follows: 

Diffuse idiopathic atrophies. 

(1) Universal— (a) senile; (b) cachectic. 

(2) Progressive— Buchwald, type. etc. 

(3) Regional — (a) kraurosis; (0) Kaposi's second type of xerodermia. 
To which he might have added congenital universal atrophy. 

For his circumscribed and secondary atrophies the original paper must 
be referred to. 



694 DISEASES OF THE SKIN. 

elastic tissue, and fibrillary structure of connective tissue; 
atrophy of all the hair structures and sebaceous glands, while 
the nerves were intact.* 

Since Buchwald's case was published, Behrend f has reported 
a case of congenital idiopathic atrophy in an infant, set. seven- 
teen months, in which the skin of the whole body, except the 
buttocks, was affected, together with onychogryphosis of the 
finger-nails. J I have met with a similar case. Touton § has met 
with a third case, a man, set. fifty-seven, in which the atrophy 
was acquired, the lesion occupying the upper and lower ex- 
tremities, beginning when he was thirty-five years old, and 
slowly extending upwards towards the trunk. Another case is 
reported by Pospelow; || the left upper extremity of a man, set. 
fifty, was affected. Groenlf met with a case of a sailor, set. forty- 
seven, in whom there was atrophy of the skin from just 
below Poupart's ligament to the toes and soles. The skin 
was thin, transparent, reddish, or cyanotic. No cause was dis- 
covered. 

Kaposi ** and Colombini f f have published cases in which 
there was diffuse atrophy affecting the whole surface very rapidly, 
for which they propose the name of dermatitis atrophicans. In 
Colombini's case, a woman, set. fifty-five, the condition came on 
after a chill, beginning on the legs, with painless red spots level 
with the skin and of various sizes. They increased in number 
and size and invaded the whole of the limbs, and the trunk par- 
tially; atrophy followed, the skin becoming shiny, slightly cor- 
rugated, finely wrinkled, and hung in folds, and was bluish or 

* Jordan, in relating a case of diffuse senile atrophy and pigmentation 
of the skin, gives references to many cases. Monatsh.f. p. Derm., vol. 
xxv. (1897), p. 373. 

f Behrend, Berlin, klin. Wochensch., 1885, No. 6, p. 88. Abs. in Viertelj. 
f. Derm. u. Syph., vol. 1885, p, 346. 

% Author's Atlas, Plate XC, Fig. 13, showing wrist, hand, and nails- 
detailed description in the text. Unna disputes the diagnosis of Beh- 
rend's case, calling it a hyperkeratosis. Mine was certainly an atrophy. 

§ Schwimmer, case 20, p. 189. 

I Richmond and Louisville Medical Journal, December, 1887. 

*{ Viertelj. f. Derm. u. Syp/i., Heft i., 1S74. 

** Kaposi, Annates de Derm., etc., vol. ix. (1898), p. 79. 

ft Colombini, " Atrophia Idiopathica," Monatsh.f. prak. Derm., xxviii. 
(1899), p. 29. Full abs. Brit. Jour. Derm., vol. xi. (1899), p. 258, with 
references. 



DIFFUSE IDIOPATHIC ATROPHY. 695 

dusky-red; the hair was thinner, shorter, and had lost color. 
The patient felt cold, constant itching (slight), and lost weight 
and strength. 

Neumann * had a similar case, also from a chill. Bronson's f 
case was symmetrical on the extremities, but the early stage 
was unknown. G. P. Elliot had another case exactly like Bron- 
son's, in which a violet zone preceded the atrophy. 

Other cases of atrophy which may be referred to are that of 
Zinsser J in a child of twelve, in spots on the hands and feet; 
that of Beer,§ which began at ten; of Beclere and Leredde || 
of Lion,f of Jordan,** a senile case; of Souques and Charcot ff 
in a girl of twenty-one, which they compared to senile atrophy 
and called it geromorphism ; it began with red lumps at the 
age of eleven, and left the whole skin in folds and wrinkles. 
Bechert's4J a woman of fifty-one, in which there was thinning, 
wrinkling, dryness, and brown discoloration over the limbs 
and part of the trunk, which began in her fifteenth year in the 
hands, when she had to have them very often in cold water. 
This case favors the view that these atrophies are the result of 
circulatory disturbance, chiefly stasis, but some cases are con- 
sidered to be angio-neuroses, and a third view is that of chronic 
inflammation, as evidenced by the cell infiltration, and shrink- 
ing of the elastic and muscular tissues, and Heller §§ regards 
some as of nevus origin.||| 

* Neumann, Archiv f. Derm u. Syph., 1898. 

\Jour. Cut. and Ven. Dis.. vol. xiii. (1895), p. 1; and Elliot's paper, p. 
152, illustrated and gives references. 

% Archiv f. Derm. u. Syph., vol. xxviii. (1894), p. 345. Abs. in Annates, 
vol. v. (1894), p. 1171. 

§ Reported in Annates, vol. iii., 1892. 

I Annates, vol. v. (1894), p. 545. 

if Archiv f. Derin. u. Syph., vol. xlv. (1898), p. 213. 

** Monatsh.f. Derm., etc., vol. xxv. (1897), p. 373. 

\\Nouvelle Iconographie de la Salpetriere, May, 1891, p. 169. Abs. in 
Annates, vol. iii. (1892), p. 873. 

%% Archiv f. Derm. u. Syph., vol. liii. (1900), p. 35, with colored plate 
of hand and some references. 

§§ Heller's case was a man of forty-five, had been affected all his life 
with patches of atrophy. Another case, a man of forty, had a patch on 
the back of right hand for three years. He gives a table of seventeen 
cases. Neumann's " Festschrift," 1900, p. 251. 

II For further details see Krzystalowicz, Histology, Monatsh.f. prak. 
Derm., vol. xxxiii. (1901), No. 8. 



696 DISEASES OF THE SKIN. 

Kraurosis, or shriveling, is an atrophy of the skin of the 
external genitals in women, first described by Breisky,* 
though Weir and Tait had previously recorded cases without 
appreciating their nature. It is a progressive cutaneous 
atrophy, limited to the vulva, and occurs chiefly after forty, but 
sometimes earlier, and in two cases after removal of the uterus, 
etc. The first microscopic changes are small vascular hyper- 
esthetic areas at the orifice of the vagina, which is narrowed 
from the skin being thinned and tense. The hair may be shed. 
The primary changes are inflammatory, but the etiology is 
unknown. It is often associated with pruritus vulvae (one-third 
Ohmann-Dumesnil), and epitheliomatous ulceration has been 
present in some cases, probably a consequence of the prolonged 
scratching. Leukoplasia precedes the epithelioma and the krau- 
rosis, according to L. Perrin; and complete extirpation of the 
affected area is strongly advocated by some authors to prevent 
the formation of epithelioma. 

Symptomatic Atrophy may be simple or degenerative, trau- 
matic or pathological. In the simple form, of which pregnancy 
scars (lineae albicantes) are the most familiar examples, the 
lesions are in appearance and anatomy the same as in idiopathic 
striae. They are especially developed during pregnancy, and at 
first are bluish-red from hemorrhage, very itchy, and get white 
eventually. Any other cause of distention, such as ascites, 
ovarian or other tumor, may produce them in the abdomen, and 
lactation has the same effect in the breasts. I have also seen 
them on the shoulders and elsewhere from large symmetrical 
lipomata, and over the lower ribs and back from violent cough- 
ing. A similar kind of lesion, though usually classed with ordi- 
nary scars, is the atrophy from external pressure, such as is 
produced by corns, favus-crusts, etc., and the depressions re- 
maining after absorption of inflammatory or other infiltrations 
of the corium, which ensue in many syphilitic lesions,f lupus, 

* Breisky, Zeitschrift f. Helkunde, Prag., March 15, 1885. See also 
a paper by Reed, N. Y. Med. Jour., September 29, 1894, p. 385, with 
histology by H. W. Bettmann, micro-photos. Weiss on Pathology; Neu- 
mann's " Festschrift," 1900, p. 944; L. Perrin, " Leucoplasie et ses rap- 
ports avec le Kraurosis Vulvae," Annates de Derm., vol. ii. (1901), p. 21. 

f Under Auspitz's name of liodermia, Finger describes an extreme in- 
stance in Viertelj.f. Derm. u. Syph., vol. ix. (1882), p. 21, with colored 
plate. 



ATROPHIA CUTIS SENILIS. 697 

leprosy, and lichen planus. These scarlike marks, if of small 
size, gradually disappear or grow less distinct, from the con- 
traction due to the natural elasticity of the skin. 

Degenerative Symptomatic Atrophy. Here, fatty, hyaline, 
and lardaceous changes occur in the same way as described in 
idiopathic senile, degenerative atrophy, and are the consequence 
of chronic dermatitis, such as eczema, pemphigus foliaceus, 
pityriasis rubra, etc., perhaps by its setting up an endarteritis, 
which is always present to a greater or less extent in these 
cases, and so diminishing nutrition. 

Treatment for all these forms of atrophy is unavailing. 



ATROPHIA CUTIS SENILIS. 

Synonym. — Atrophodermia senilis. 

The condition is usually associated with general signs of 
senile degeneration. It may affect the whole skin, its ap- 
pendages, and subcutaneous tissues, may be simple or quanti- 
tative, degenerative or qualitative, or more often both. 

The skin is more or less in folds from loss of fat, less elastic, 
slightly shrunken, wrinkled, and from atrophy of the glands is 
dry, sometimes with fine branny desquamation; it feels thin, 
and is transparent and shining. The hair is lanugo-like or 
absent. Pruritus, which may be severe and persistent, is some- 
times present, but the reaction to scratching is slight or 
absent. In a case of Harrison's of Bristol a condition like 
white lichen planus was produced. It may be paler, but is more 
often darker than normal, sometimes even a tawny brown, or it 
may take the form of freckles,* often very large and dark. 
Various new growths are liable to arise. The arms, trunk, and 
neck may be studded with numerous flat warts, deeply pig- 
mented, of a dirty brown or black color, and if the horny cover- 
ing be picked off, hypertrophied papillae are exposed, or the 
dilated orifice of a sebaceous gland which was plugged with 
accumulated epidermis. Some pendulous sacs of skin, the con- 
tained fibromata having atrophied, are frequent on the neck and 

♦See under Eczema a case of freckles following it ; also Hutchinson on 
" Tissue dotage," Archives, vol. iii. p. 315. 



698 DISEASES OF THE SKIN. 

trunk; and scattered about are bright crimson, very slightly 
raised spots, consisting of tufts of dilated vessels. Soft mole- 
like growths may also be present, and some one or other 
of these ill-nourished structures often take on a malignant 
growth. 

Epithelioma and rodent ulcer are especially the new growths 
of old age, but wens, senile lupus, senile scrofula, and the small 
fibromata alluded to, are also not infrequent. Another condi- 
tion is the presence of flat yellow discs about an eighth of 
an inch in diameter, due to hypertrophy of the sebaceous glands 
(see that disease); they occur chiefly on the forehead and other 
parts of the face. 

Anatomy. — Neumann found the epidermis thinned and forming a wavy 
line over the shrunken papillary layer. The corium generally was 
thinned and its connective tissue corpuscles fewer and smaller, with pig- 
ment granules among the fiber bundles ; the vessels were in some cases 
destroyed, in others enlarged, and contained pigment masses. The 
papilla of the hair was often shrunken, and the cells of the outer root- 
sheath cornified and sometimes bulging out the follicle ; many of the 
sebaceous glands were enlarged, at least in some of their acini, which 
were filled with crumbling epidermic masses ; the fat cells were here 
absent, leaving the connective tissue meshes empty. 

Degenerative Atrophy. In this the connective tissue fibers 
lose their definition from being clouded with granules, and be- 
come changed into more or less homogeneous tough or brittle 
masses; these changes are known as granular or vitreous de- 
generation, and some speak of lardaceous and fatty changes. 

Colloid degeneration of the corium is described along with 
new growths. 



strle; et macule atrophica. 

Synonym. — Atrophodermia striata et maculata. 

Symptoms. — This condition may be idiopathic or symptomatic. 
The idiopathic form occurs as streaks and spots; the " streaks " 
are pearly or bluish-white, glistening scarlike lines from one to 
several inches long and a quarter of an inch or more wide. 
They lie in two or more parallel lines, inclined at various angles 
to the longitudinal axis of the body, following the natural lines 



STRI& ET MACUL2E ATROPHICA. 699 

of cleavage of the skin, and are situated chiefly about the but- 
tocks, the anterior border of the ilium, the trochanters and 
thighs, rarely on the neck, trunk, or arms. They are slightly 
depressed below the surface, and the skin is evidently thinned 
there. 

Wilson has described cases of linear atrophy which he consid- 
ered due to defective nerve supply, but one of the cases followed 
a blow, and another was the consequence of violent sneezing, 
so that the possibility of a traumatic origin cannot be quite 
excluded. The lesions were situated in the course of the supra- 
orbital nerve, beginning by a faint white line with slightly red 
borders, the white part being widened and deepened; sensibility 
was lost, and the skin became dry. Subsequently the sides of 
the sulcus were drawn together, leaving " a deep linear groove, 
like a sword-cut." Another case * bears out his contention with 
greater probability. A young lady was turned out half-dressed 
on a cold night, as the house was on fire, and straight parallel 
lines of atrophy developed on the forearm. It is very probable 
that they are related to, perhaps only variants of, supra-orbital 
sclerodermia, which is often associated with atrophy. 

Maculae Atrophica?. The " spots " are less common; they are 
from a lentil to half a crown in size, also shiny white or bluish, 
and level with the skin or slightly depressed, finely wrinkled, 
usually isolated, and are seen mostly on the trunk and neck. 
Both lesions make their appearance unnoticed by the patient, 
as a rule, and give rise to no inconvenience, but they, never 
go away entirely, though they may get less obvious from the 
natural elasticity of the healthy skin drawing the sides together. 
There is much reason to believe that this is a secondary condi- 
tion. Liveing observed a case of the macular variety, where the 
spots were in all stages, and found that the first was charac- 
terized by slight redness and by well-marked hypertrophy rather 
than atrophy, for the spots were raised above the skin, and were 
hard and fibrous. This was soon followed by the second char- 
acteristic white stage, and in some of them by a third, consist- 
ing of a shrinking process, which drew the healthy surrounding 
tissues together, and the spots became barely perceptible. 
Taylor of New York and Tilbury Fox also mention hyperemia 

* Jour. Cut. Med., July, 1867. 



7 oo DISEASES OF THE SKIN. 

as an antecedent condition. Jadassohn * described a case where 
the spots varied from a lentil to a shilling all over the extensor 
aspect of the limbs in a young woman ; they were shown to have 
followed light red, slightly raised papules. In Sherwell's case f 
the spots were all small, situated on the backs of the hands, 
feet, and all up the leg, below the knee, and on the upper limbs 
also. They were said to have begun with red itching papules 
which became white and left these pits. In Pospelow's case J 
the atrophic spots occurred in a patient with defective circula- 
tion following on petechia?; microscopically he found inflamma- 
tion of the vessel walls and absence of elastic tissue; while con- 
sidering it of the same nature as Jadassohn's case he proposed 
to name it purpura atrophicans. Heuss § records a case of the 
Jadassohn type. He found perivascular infiltration in the early 
stage, and in the later almost complete disappearance of the 
elastin in the atrophic area. 

The vitiligo of Bateman, which differs from that of Willan, 
appears to belong here, but the tubercles are white from the 
beginning; he describes it thus: " It is characterized by the ap- 
pearance of smooth, white, shining tubercles, which rise on the 
skin, sometimes in particular parts, as about the ears, neck, and 
face, and sometimes over nearly the whole body, intermixing 
with shining papulse. They vary much in their course and 
progress; in some cases they reach their full size in the course 

* " Ueber eine eigenartige Form von 'Atrophia Maculosa Cutis,'" 
Verha7idl. der deutsch. derm. Gesellsch. Congress, 1891. He discusses 
many other reported cases. 

\ Amer. Jour. Cut. and Gen.-Urin. Bis., vol. xii. (1894), p. 499. 

% Shown at the Derm. Soc, Moscow, in March, 1899. 

%Monatsh.f. prak. Derm., vol. xxxii. (1901), Nos. 1 and 2, with colored 
histological plate and many references. Abs. Brit. Jour. Derm., vol. 
xiii. (1901), p. 198. He classifies the cases as follows : 

1. Primary or idiopathic. Atrophia maculosa cutis, including Thi- 
bierge's, Jadassohn's, Heuss', Galewski's, and Mibelli's, perhaps also 
Besnier's cases. 

2. Secondary forms in connection with : 

a. Vascular changes — as in Pospelow's, Nikolsky's, and Hallopeau's 
cases. 

0. Tumors, especially of connective tissue nature. De Amicis' and 
Plonsky's cases. 

7. Followed by growths, especially keloids— Jadassohn, Schwimmer, 
Schweninger and Buzzi cases. 



STRI& ET MACULM ATROPHICA. 701 

of a week (attaining to the magnitude of a large wart), and then 
begin to subside, becoming level with the cuticle in about ten 
days. In other instances they advance less rapidly, and the 
elevation which they acquire is less considerable — in fact, they 
are less distinctly tubercular. But in these cases they are more 
prominent, and, as they gradually subside to the level of the 
surface, they creep along in one direction, as, for example, 
across the face or along the limbs, checkering the whole super- 
ficies with ' a veal-skin ' appearance. All the hairs drop out 
where the disease passes, and never sprout again; a smooth, 
shining surface, as if polished, being left, and the morbid white- 
ness remaining through life. The eruption never goes on to 
ulceration." 

Tilbury Fox * records a case which he considers referable to 
Bateman's vitiligo, but the tubercles were slower in their evolu- 
tion. 

Etiology. — Both striae and maculae are seen in adults of both 
sexes, and at all ages, but Schultze found that thirty-six per 
cent, were women who had never borne children, and only six 
per cent, were men, and they were more frequent in tall men. 
This applies only to the striae, which he considered due to the 
stretching of the skin during the expansion of the pelvis and 
growth of the limbs. Morris showed a case at the Dermatologi- 
cal Society of a girl of twelve, in whom there were long wide 
streaks across the thighs, apparently due to rapid growth, as she 
had had no illness. The cases of striae which are sometimes 
observed in convalescence from typhoid fever in the limbs of 
children and young adults are chiefly across the ankles, and 
presumably due to the pressure of the bedclothes producing 
overextension, w T hen the nutrition of the skin is damaged by 
the fever. When, as in Duckworth's case,f they are across the 
thighs, they are in some cases probably due to the rapid growth 
often observed under such circumstances. In Shepherd's case t 
in addition to broad stripes across and above the knee there were 
atrophic spots, which was the earliest lesion, and the striae were 
formed by their enlargement and coalescence. These atrophies 

* Lancet, June 28, 1879. 

f Duckworth, after relating his own case, gives many references in 
Brit. /our. Derm., December, 1893, vol. v. 
% Amer. Jour. Cut. Dis., vol. ix. (1891), p. 59. 



7 o2 DISEASES OF THE SKIN. 

occur in the most severe adynamic cases. Osier has observed 
similar striae on the arms and legs after scarlet fever. Exam- 
ples of what may be called distention stria? may be seen on the 
thorax from pneumothorax, rapid development of fat,* either 
on the trunk or limbs, rapid growth of a limb either ordinary 
or extraordinary, as in some cases of diseased bone attended 
with elongation, the distention of pregnancy, or ascites, or 
flatulence. In two of Hanot's cases lymphatic varices in asso- 
ciation with ascites left striae atrophica? when the varicosity sab- 
sided. After tapping Fere and Schmidt found that in fifteen 
per cent, of epileptics there were striae in the lumbo-sacral 
region, attributed to disproportionate length of the spinal 
column in that region. 

In Ohmann-Dumesnil's f case, a girl, when two and a half 
years old, had a deep burn on the radial side of the wrist close 
to the root of the thumb; when seven years old the whole limb 
was, to some extent, wasted, and on the arm and forearm were 
five atrophic, scarlike, linear striae three-eighths of an inch 
wide, and lying over the brachial and radial nerves. There was 
also slight hyperesthesia. These lesions were clearly neurotic. 
No satisfactory explanation of the maculae has been afforded. 
Wilson's cases and the antecedent hyperemia of some others 
favor to some extent a tropho-neurotic origin, in some instances 
at all events, a view Schwimmer strongly advocates. 

Anatomy. — Langer and Kaposi have found atrophy of the epidermis, 
obliteration of the papillae, separation of the connective tissue fibers, and 
diminution of the glands, vessels, hair-follicles, and fat lobules, partly 
from atrophy, partly from separation. 

In Plate XV. of the International Atlas Schweninger and 
Buzzi describe a case of a rare affection, which they designate 
Multiple, Benign, Tumorlike, New Growths. It has also 
been observed by M. Morris, Colcott Fox, and Van Hoorn. 

Clinically, the lesions are soft, round, or oval projections, 
from a lentil to a bean in size, more or less white, with a slight 
bluish or slate color in some of them. Most of them are 
bladderlike, and can be pressed into the skin by the finger, pro- 

* R. W. Taylor, in N. Y. Med. Jour., January 2, 1886, published with 
colored lithograph a remarkable instance of striae from obesity and 
flatulence. 

\ Brit. Jour. Derm., vol. ii. (1890), p. 246. 



GLOSSY SKIN. 703 

jecting again immediately like a hernia. The larger ones are 
flattened and slightly puckered, and harder than the smaller, 
from which they develop. They undergo spontaneous involu- 
tion, and leave only flaccid, loose, foveated scars. They appear 
very gradually and without sensory symptoms on the trunk, 
shoulders, and thighs, and ultimately become numerous, as none 
disappear entirely, and others keep forming. Three out of the 
four cases were women. One had had syphilis, and she stated 
that the lesions appeared on a secondary eruption, which did 
not ulcerate; but in the other cases there was no evidence of 
syphilis. 

Microscopically, Buzzi found that they were not true tumors, 
but the projections were produced by the skin alone, in which 
the elastic fibers were quite absent, with slight increase of them 
at the border of the pseudo-tumor. Around the vessels of the 
superficial horizontal network and the skin appendages there 
were round-cell accumulations and evidence of proliferation of 
the compound elements. The passive retraction of the elastic 
tissue was the primary change, as it was constant in the smallest 
lesions, which appear therefore to belong more to atrophy than 
to new growth, resembling somewhat maculae atrophica?, but 
forming projections instead of depressions. 

I have seen very similar lesions associated with fibromata of 
the ordinary form, when some of them have been absorbed. It 
is probable that they are the last phase of more than one patho- 
logical process. 

From the nature of the lesions treatment has not been, nor 
is likely to be, of any avail. 

GLOSSY SKIN.* 

Synonym. — Atrophodermia neuritica. 

Symptoms. — Under this title Paget, Weir Mitchell, and others 
have described an atrophy of the skin in the area of a nerve 
affected by disease or injury. It chiefly attacks the extremities, 
perhaps only one or two fingers; the skin of the affected part 

* Literature. — Paget, " Some Forms of Local Paralysis," Medical Times 
and Gazette March 24, 1864. Weir Mitchell, " Injuries of Nerves and 
their Consequences," (Philadelphia, 1872). Moorhouse and Keen, " Gun- 
shot Wounds and Other Injuries of the Nerves " (Philadelphia, 1864), 



7o 4 DISEASES OF THE SKIN. 

becomes very dry, smooth, and glossy, like a thin scar; the 
fingers are tapering, hairless, and almost void of wrinkles, and 
the color is pink or deep red, not unlike chilblains, or mottled 
with patches of red and white, and the skin is easily inflamed, 
excoriated, and fissured. A severe and persistent burning pain 
(causalgia) precedes and accompanies this condition, and is very 
characteristic. The appendages of the skin share in these de- 
fects, hence the dryness, loss of hair, and changes in the nails, 
which Mitchell and Moorhouse and Keen regard as in them- 
selves quite distinctive. The nail is curved both longitudinally 
and transversely, and there is sometimes thickening of the cutis 
beneath the free end. In some cases the skin of the third 
phalanx retracts, partially exposing the sensitive matrix; at the 
free end the nail is also more separated than usual from the 
cutis, which is seen as a notched border through the nail. In 
the toes, with painful and recurring ulceration at the angles, 
there is less deformity. Instead of dryness the sweat is often 
increased considerably, is intensely acid, and sometimes of- 
fensive. 

Etiology. — It follows such injuries to nerves as do not com- 
pletely sever them, or it may arise from a neuritis being set up 
in a wound. It has also been found as a complication of gout, 
rheumatism, non-tuberculated leprosy, and following shingles, 
and in a few cases of chronic myelitis, in one of which there was 
associated muscular atrophy. 

Pathology. — The disease is undoubtedly dependent upon in- 
flammation of the nerve supplying the affected area, whether the 
neuritis is set up by disease or injury. In the cases associated 
with disease of the cord the condition of the nerves was not 
examined. Whether the neuritis is interstitial or parenchy- 
matous, or both, has not been investigated. In a case reported 
by A. E. Watson * of apparently spontaneous origin, the 
" causalgia " was very acute, lasted about twenty-four hours, 
and shifted from one hand to the other ; the right hand suffered 
two attacks. The fingers were white and shiny during the at- 
tacks. The history suggests that the lesion was in the periphery 
of the nerve. 

Treatment. — The condition tends to get well spontaneously, 
and only requires, therefore, protection from cold and other 
* Lancet, vol. i. (1890), p. 647. 



PERFORATING ULCER OF THE FOOT, 705 

injurious influences. The causalgia is generally best relieved 
by the constant application of cold water, but in Watson's case 
this aggravated the suffering, and immersion in very hot water 
produced immediate removal of the pain. 

PERFORATING ULCER OF THE FOOT. 

This somewhat rare disease comes under the care of the 
general surgeon rather than the dermatologist, and requires, 
therefore, only a brief notice here. Its neurotic origin has been 
well brought out in a paper by Savory * and Butlin, whose ob- 
servations have been confirmed and extended by subsequent 
observers. 

The exciting cause is pressure or injury of some kind to a 
foot in which the protecting nerve influence is in abeyance, 
either from damage to the nerve center, as in locomotor ataxy, 
which is the most common cause; to the nerve trunk (the pos- 
terior tibial), as in syphilis, leprosy, or other cause of neuritis; 
or to the peripheral terminations of the nerve, as in peripheral 
neuritis. 

Gasguel f collected 91 cases, 84 of which were in males. The 
age was stated in 79: 3 were under twenty, 4 between twenty 
and thirty, 22 between thirty and forty, 31 between forty and 
fifty, and 19 were over fifty. In 69 cases there was a central 
nervous lesion, 8 times there was peripheral nerve lesion, and 
14 were diabetic. Thirty-two had tabes, 17 general paralysis, 8 
symptoms of alcoholism, 4 traumatic disease of the cord; 8 had 
various cord lesions, 1 being Friedreich's disease. 

Symptoms. — Although the foot is the usual seat of the so- 
called ulcers, Terrillon $ showed a case to the Societe de 
Chirurgie where the hand was affected at the junction of the 
ring finger to the palm, and Menetrier § records several ulcers 
on the palmar surface in a syphilitic whose hands were con- 

* Med. Chir. Trans., vol. lxii. (1879), P- 373, with colored plate and 
microscopic drawings of nerves and full bibliography. For some recent 
references see also Tomasczewski in Munch, med. Wochensch., No. 20, 
May 20, 1902, p. 843. 

f " These de Paris," July, 1890. 

-\ Quoted in Lancet, April 11. 1885, p. 676. 

§ Annates de Derm., etc., vol. vii. (1886), p. 30. 

45 



706 DISEASES OF THE SKIN* 

stantly wet and dry at his work.* The most common position 
is where there is most pressure, such as over the metatarso- 
phalangeal joint of the great or little toe, or the pulp of the 
great toe, always on the plantar surface. There may be more 
than one on the same foot, and both feet may be affected. It 
is more correctly a sinus than an ulcer, and often begins by 
suppuration under a corn, burrowing into the soft tissues, and 
when the horny covering is thrown off a sinus is exposed, lead- 
ing down to the bare bone; sometimes the process is more 
acute, and a slough is rapidly formed, but the result is the same. 
As the pressure from walking is continued, the epidermis round 
the ulcer becomes much thickened, and forms a thick horny 
collar round the sinus; occasionally there are granulations 
round the orifice. It is very indolent, generally painless, even 
on pressure, anesthesia of the neighborhood being the rule; but 
occasionally there is hyperesthesia, and there is a tendency to 
abundant and fetid perspirations of the affected foot. 

The only affection from which it requires to be distinguished 
is an ordinary suppurating corn, unconnected with damage to the 
nerve of supply; this will be distinctly painful, the skin round 
will be very sensitive, and although there may be a sinus lead- 
ing down to necrosed bone, treatment on ordinary surgical 
principles will always be satisfactory. In the true perforating 
ulcer the reverse is the case, although the sinus may be induced 
to heal under very prolonged rest. The bucket-leg is the most 
practicable way of resting the foot, without absolutely laying the 
patient up, but it is sure to break out again as soon as he begins 
to walk. Amputation of more or less of the foot by Chopart's, 
Syme's, or Pirogoff's operation is recommended in most surgical 
works, but the cause being unremoved, a fresh ulcer is very 
apt to form in the stump. The treatment suggested by Treves 
seems rational, and is successful in most cases. The thickened 
epidermis round the sinus was pared down completely, after 
softening by repeated poultices, and the sinus filled up with a 
cream of salicylic acid, glycerin, and ten minims of carbolic 
acid to the ounce, and after healing, which soon occurred, a 

* Fitch is quoted by Montgomery of California, as having observed "a 
perforating ulcer of the wrist, which bored clear through the carpus," in 
an infant of six months old, one of a leper family. 

Instances of spontaneous cure in a leper family. D. W. Montgomery, 
Med. Rec, April 10, 1902. 



MORVAN'S DISEASE. 7 o 7 

thick perforated felt pad was worn over the sore, the hole cor- 
responding with the former sinus, and care was taken, by atten- 
tion to the construction of the stockings and boots, to prevent 
fresh injury. Beaven Rake, who had a large number to treat 
in the Trinidad Leper Asylum, recommends that stretching of 
the sciatic or posterior tibial nerve, free incision of the ulcer, 
and opening up the sinus, should be tried before amputation is 
resorted to. Chipault reported five cases of trophic perforating 
ulcers successfully treated by stretching the plantar nerves. In 
some cases it might also be desirable to stretch the musculo- 
cutaneous and external saphenous nerves. The operation 
should be at some distance from the ulcer to avoid infection of 
the incision from it. 

MORVAN'S DISEASE.* 

Synonyms. — Analgesic paralysis with whitlow; Syringomyelia; 
Fr., Panaris analgesique. 

This is a rare disease first described by Morvan of Lannilis 
in Brittany in 1883. It is a trophic affection from disease of the 
spinal cord which only requires brief mention here, although 
its interest to dermatologists has been considerably increased 
since Zambaco Pacha put forward the theory that it is really an 
atavistic and attenuated form of leprosy. 

Symptoms. — The first symptom is pain in the extremities, fol- 

* Literature. — Five memoirs by Morvan in Gazette Hebdomadaire, 
1883-1889, and by Prouff, loc. cit., 1887. Lecture by Charcot, Progr. 
Medical, March, 1890; translated Phil. Med. Bulletin, Nos. 10 and 11, 
1890, from which the above description is chiefly taken. In Brit. Jour. 
Derm., vol. ix. (1897), p. 207, is an abs. of P. M. on one of the cases in Char- 
cot's lecture. See also " Les alterations cutanees et la syringomyelic" 
G. Thibierge, A tin. de Derm, et de Syph. Bruhl's " Contribution a 
l'etude de la syringomyelic, " Paris, 1890, gives a very complete account. 
Also a case by Hughlings Jackson, Lancet, February 20, 1892. In Part 
VI. " Internat. Atlas," with Plate XVIII., L. Jaquet gives an account of a 
case of syringomyelia, with extensive trophic ulcerations on the head, 
neck and shoulder. " Morvan's Dis.," Hogarth Pringle, Brit. [our. 
Derm., vol. v., July, 1893, p. 193. Cagney on " Syringomyelia and Lep- 
rosy" — a good resume oi the then known facts, Trans, of the Derm. Soc. 
Great. Brit, and Ireland, vol. i. (1895), p. 53. " Morvan's Dis., Syring- 
omelia and Leprosy," Jeanselme, La Presse Medicate, No. 62 (1897), p. 
44. Good abs. Brit. Jour. Derm., vol. ix. (1897), p. 454, one of the cases. 



7 o8 DISEASES OF THE SKIN. 

lowed by analgesia, first of one side, then of the other, and then 
the formation of a succession of whitlows, which are usually 
painless, though the early ones are sometimes painful. The 
whitlows are attended with, or are the result of, necrosis of the 
phalanges, which are cast off with much consequent deformity 
and crippling. There are usually only from two to six of these 
whitlows, but one of Morvan's cases had nine. They affect the 
upper extremities chiefly, but the toes have been involved in 
some cases. 

They may be distributed over many years, sometimes with 
long intervals of freedom. In Prouff's case, the earliest and 
longest on record, the duration was forty years (from the age 
of twelve to fifty-two), and there were twenty years between 
the first four whitlows on the right hand and the last four on 
the left. A patient of mine, a woman, aet. fifty-one, had suffered 
from whitlows on the right index and left thumb for thirty-five 
years. The first appeared on her right middle finger, but all 
the rest on the above-mentioned digits; she was scarcely ever 
quite free; the longest interval she remembered was two 
months. They were painful, and there was some deformity of 
the terminal phalanges. There were no other symptoms of 
Morvan's disease. 

There may be other trophic lesions of the skin, of the fore- 
arms and hands, viz.: fissures, shallow or deep, ulcers in the 
natural folds of the skin, almost amounting to the perforating 
ulcer, extending with suppuration to the tendinous sheaths 
(Charcot). Patches of bullae and pustules sometimes are pres- 
ent. Further vaso-motor symptoms occur chiefly of the hands. 
Pospelow * had a case with Raynaud's disease and concomitant 
sclerodactylic erythromelalgia and edema of the hands and fore- 
arms, irregular herpes zoster gangrenosus and analgesic whit- 
lows, in association with spinal glioma. A dusky color only 
with lowering of temperature is observed more frequently than 
a typical Raynaud. 

Other trophic symptoms are muscular atrophy and paresis 
of the forearm and hand muscles, and contraction of the fingers, 
with " main en griff c " with impaired electrical contractility. 
The paralysis seldom extends beyond the elbow; Morvan said 

* In " Festschrift " of F. J. Pick in 1898, illustrated. Reviewed in Brit. 
Jour. Derm., vol. x. (1898), p. 418. 



MORVAN'S DISEASE. 'jog 

it never did. Morvan stated there was complete analgesia and 
anesthesia, affecting the sense of pain, touch, and temperature, 
while in typical syringomyelia tactile sensation is preserved, 
that of pain is absent, and the sensations of heat and cold are 
more or less lost. But this is only true of some cases, since 
Joffroy, with and without Achard, and Marinesco have found 
syringomyelia at two autopsies of typical cases of the disease of 
Morvan, and in spite of the latter's protests there is now a 
conviction that this condition is only a clinical variety of 
syringomyelia, in which the cavities are often produced by the 
absorption of gliomata, the central and posterior portions of the 
cord being the parts chiefly involved. 

Most cases occur between twenty and fifty, but twelve and 
sixty years are the extremes observed. It is more common in 
men than women. Hanot's case started definitely from a chill, 
the man having continued his work after having fallen into a 
river. A few have started from injury. In most the cause is 
untraceable. 

Charcot gives the diagnosis of Morvan's disease from sclero- 
dermia of the hand and anesthetic leprous deformity of the 
hand, but the other symptoms of those maladies would be pres- 
ent, so that mistakes could seldom arise except from paying 
too exclusive attention to the hand lesions. Rendu * met with 
a case from Tongking with the special dissociation of sensory 
symptoms of syringomyelia, which Charcot, Leloir, and Hal- 
lopeau considered to be anesthetic leprosy, the patient having 
thickening of the ulnar nerve and paralysis of the orbiculares 
palpebrarum, as well as trophic troubles of the lower limbs. 

There are, therefore, some cases in which the diagnosis is 
difficult, and it is now established that syringomyelia with its 
characteristic spinal cavities may occur in the course of leprosy, 
as may also analgesic whitlows and mutilation, anesthesia, 
vaso-motor, and trophic disturbances. Zambaco, who has had 
long experience of leprosy in Constantinople, struck by these 
resemblances, went to Brittany, where Morvan observed his 
cases, and came to the conclusion that leprosy was not dead 
there, and that syringomyelia and Morvan's disease were only 
forms of leprosy modified by climate, hygiene, and environ- 

* Jeanselme records a case of Morvan's disease in a leper, loc. cz't., Fr. 
Soc. Derm., Ann. de Derm, et de Syph., vol. ii. (1891) p. 409. 



710 



DISEASES OF THE SKIN. 



ment. This startling theory was considerably weakened by his 
further contention that, " Sclerodermia, sclerodactylia, morphea, 
ainhum, are all modified forms of leprosy"; and further, that 
cases of leprosy have been included under Raynaud's disease 
and the progressive muscular atrophy of Duchenne. Zambaco 
has found a few supporters, such as Falcao of Lisbon and Coli 
of Columbia, but most people consider that the Pacha has 
proved too much, and that similarity of symptoms and even of 
pathological changes does not necessarily imply the same patho- 
genic agent. 

The prognosis is not good, and treatment can only be pal- 
liative. 

AINHUM.* 

(The Nagos native name, meaning " to saw.") 

Definition. — An endemic disease, in which spontaneous am- 
putation of the little toe occurs. 

This disease occurs only in negroes and Hindoos and other 
dark-skinned races. 

It is not uncommon on the Gold Coast and other parts of the 
west coast of Africa, and in Brazil, and is also to be met with 
in the West Indies, West Virginia, North Carolina, India, 
and the islands of Polynesia, Nossi-Be, Reunion, and Mada- 
gascar. It was first described by Clarke as "a dry gangrene of 
the little toe among the natives of the Gold Coast," and inde- 
pendently years later by Da Silva Lima of Bahia, who collected 
fifty cases. 

* Literature. — Clarke. Trans. Epidem. Soc, i860, vol. i. p. 105. "On 
Ainhum," by Da Silva Lima, Amer. Arch, of Derm., 1880, vol. vi, p. 367 — 
one of the best accounts of the disease. See also Hirsch's " Geographical 
and Historical Pathology," New Sydenham Soc, 1886, vol. iii. p. 728, con- 
taining bibliography. Duhring, Amer. Jour. Med. Sci., January, 1884, with 
microscopical examination by H. Wile. " The Histology of Ainhum," by 
C. H. Eyles, Lancet, September 25, 1886. Path. Soc. Trans., vols, xviii., 
xix., and xxxii. (1881), p. 302 ; and Fox and Farquhar's " Endemic Skin 
Diseases of India," etc., App. vii. p. 114. "Ainhum," by Walter Pyle 
of Washington, Medical News, January 26, 1895, gives a full bibliog- 
raphy. " Contribution nouvelle a l'etude de la question de TAinhum," 
par H. de Brun, de Beyrouth, Annates de Derm., etc., vol. x. (1899), p. 
325, with skiagram. 



AINHUM. 711 

Symptoms. — The disease is a purely local one, and begins as 
a semicircular furrow in the digito-plantar fold of the fifth toe, 
starting from the inner and under surface, without inflammatory 
or subjective symptoms, except perhaps itching, preceding or 
accompanying it; nor is there at first any breach of surface or 
interference with the movements or sensibility. The furrow 
extends very slowly in depth, and towards the upper surface, 
eventually completing the circle and forming a groove all round, 
as if from constriction by a ligature, and with the same result, 
the portion beyond the constriction swelling up to two or three 
times the normal size and becoming separated from the rest, 
with the top part rotated outwards. While the constriction 
deepens the tissues atrophy beneath, so that the toe is like 
a roundish tumor with a narrow, flexible pedicle, which at this 
stage is likely to ulcerate, with fetid discharge and severe pain, 
until the now useless member is removed, either by the occur- 
rence of gangrene, an accidental wrench, or being cut off by the 
surgeon or the patient himself, which he can easily do with 
little pain or bleeding. All this process is very slow, taking 
from four to ten years for the toe to be ready for removal, but 
fifteen (Moreira) and fifty (Evans *) have been recorded. 

Mr. Johnson Smith was kind enough to show me at the Sea- 
men's Hospital, Greenwich, the only living case that had, up to 
then, visited England. The patient was a stalwart negro sailor, 
set. thirty-eight, from Jamaica, and he had noticed the disease 
for seven months. Unlike most cases, pain was the first symp- 
tom. This had persisted ever since, slight in the daytime, but 
severe at night, quite preventing sleep, and he therefore wished 
the toe removed. There was no ulceration; but in the plantar 
fold, opposite the metatarso-phalangeal joint, the epidermis was 
much thickened, and on the inner side was a sulcus like a deep 
cut. On the upper surface the furrow was shallow, but broader, 
and on the outer side what appeared to be a corn leveled up the 
sulcus. It is noteworthy that in Shepherd's case the disease 
began as a small pimple on the outer side of the toe. Not in- 
frequently the fifth or the fourth toe on the other foot, or the 
fourth and fifth of the same foot, or even the great toe (Craw- 
ford and Cooper), are also attacked simultaneously or succes- 
sively, and Beranger-Ferraud has seen all the toes amputated, 
* Evans, Trans. South Carolina Med. Assoc, 1897, p. 93. 



712 DISEASES OF THE SKIN. 

and in one case all the toes of the right foot were lost and the 
disease began in the middle third of the leg. The metatarso- 
phalangeal joint has been affected in a few cases, and Eyles 
once saw it affecting a finger, but nine times out of ten it is con- 
fined to one or both little toes. 

Etiology. — It occurs chiefly in adults who are young or in the 
prime of life (thirty to thirty-five), rarely in old age, and hardly 
ever under fifteen years; Le Brun's case was six years old. It 
affects the male sex much more than the female, and is said to 
be sometimes hereditary (Da Silva Lima, Duhring, Dupouy), 
but this has not been proved and is a priori improbable. These 
facts, and its restriction to the dark races * and to certain locali- 
ties, are all we know of the causation of the disease. Some 
authors ascribe it to injuries resulting from the negroes walking 
barefooted. This is disputed, however, because freed negroes 
who wear shoes are also affected, but it is notorious that they 
take them off whenever they can. Their flat-footedness is sup- 
posed to explain the fact that the fourth and fifth toes are the 
ones affected. It has also been attributed to wearing rings on 
the fifth toe, but it occurs in races which do not wear rings. 

Pathology. — Nothing is known of its pathology; but its histol- 
ogy has been many times investigated. According to Eyles, 
one of the most recent observers, there is hyperplasia of the 
epidermis, especially of the horny layers, and downgrowth of 
the interpapillary processes. In the corium there is great in- 
crease of fibrous tissue and fat; in the vessels, and in the larger 
arteries, there is great increase of the adventitia, the middle 
coat is but little altered, while the intima in most of the vessels 
is much thickened, so as to encroach upon, and even fill up, 
the lumen, i. c, there is endarteritis obliterans. In the bones the 
condition is one of " rarefying osteitis." Still later Moreira f 
of Bahia finds a chronic inflammation of the upper layer of the 
cutis, and a fibrous hypertrophy of the collagen tissue in the 
area of the furrow. He found no leprosy bacilli or other micro- 
organisms. The bone tissue is gradually absorbed, and is re- 

* Cases of ainhum in Europeans have been reported by Mirault, Fion- 
tan, and others, but they are not accepted as genuine cases. 

f J. Moreira, Monatsh. f. prak. Derm., xxx., No. 8, p. 361, with three 
figures. Abs. Brit. Jour. Derm., vol. xii. (1900), p. 334. Clinical details 
of nineteen cases. The histology was done in Unna's laboratory. 



AINHUM. 7I3 

placed by fibrous tissue. Other authors describe the conversion 
of the soft tissues and bone into a uniform fatty mass. The line 
of the division may occur either through the middle of the prox- 
imal phalanx, or at the proximal inter-phalangeal joint 
(Crombie). 

Zambaco's view that it is a modified leprosy was put forward 
in 1867 by Collas, but is scarcely worth discussion. 

Manson suggests that it is due to frequently repeated irrita- 
tion from injuries in walking barefooted, setting up fibrous 
changes to which the negro race are especially liable, e. g., their 
proneness to keloid. 

Treatment. — Da Silva Lima found that at the commencement 
division of the contracting band by incision at right angles to 
its course cured the disease. Murray of Trinidad confirms this. 
At the later stage there is nothing to be done but to amputate 
the toe as soon as it becomes painful or troublesome. 

Proust * has endeavored to show that ainhum is pathologi- 
cally identical with congenital amputation, but this view is not 
accepted. 

* Gazette des Hopitaux, April 4, 1889. See also the refutation by Trelat, 
Gaz. Hebd. de Med. et de Chir., February 28 and March 7, 1891, pp. 102, 
113, and abs. in the Ann. de Derm, et de Syph., vol. ii. (1891), p. 614. 



CLASS VII. 
NEUROSES— SENSORY DISEASES. 

NEUROSES CUTANEA. 

As a matter of practical convenience the neuroses of the skin 
are restricted to disturbances of its sensory innervation, the 
symptoms of which are entirely subjective, the changes being 
functional only; any visible effects, such as may be due to 
scratching, are secondary or accidental. 

These affections come under excess or diminution of sensi- 
bility, i. e., hyperesthesia, dermatalgia, pruritus, and anesthesia. 

HYPERESTHESIA. 

Exalted sensibility of the skin may be idiopathic or symp- 
tomatic; practically nearly all cases are symptomatic. It 
may be general or local, perhaps restricted to one nerve 
domain, symmetrical or unilateral, and due to functional 
or organic disease of the nerve centers, trunks, or peripheral 
terminations, and of an irritative rather than of a paralytic 
kind. The chief cause with which dermatologists have to do 
is hysteria, and even then it is only one of many phenomena at- 
tending that condition. It is present in a slight degree in some 
cases of urticaria factitia; at the onset of non-tuberculated 
leprosy, generally in the course of the ulnar or sciatic nerves; 
and in neuroma cutis. The surface may be so sensitive that the 
slightest touch even of the clothes is painful; and changes of 
temperature, or a mere breath of air, produce more or less dis- 
comfort, and in hydrophobia, a characteristic and painful spasm. 
Its duration depends upon its cause; in hysteria, for example, 
it may shift its position from one side to the other, and come 
and go in an inexplicable manner. There are, however, a few 
cases in which there is no apparent cause, and these are classed 
as idiopathic. 

For the paresthesias of various kinds met with as a symp- 

7*4 



DERMATALGIA. 715 

torn of many nervous diseases, central and peripheral, works on 
neurology should be consulted. 

DERMATALGIA. 

Synonyms. — Neuralgia of the skin; Rheumatism of the skin; 
Fr., Dermalgie; Gcr., Nervenschmerz der Haut. 

Definition. — Pain in the skin, not consequent upon structural 
change in it. 

Piorry, Beau, and Axenfeld have specially studied this condi- 
tion. While in a few cases it appears to be primary, more fre- 
quently it is due to some organic disease of the nerve centers, 
especially locomotor ataxy. 

In a considerable number of cases there is a history of rheu- 
matism, as was first pointed out by Beau, and exposure to cold 
has been the direct exciting cause. Chlorosis has been present 
in some cases, and hysteria in many, while in others there has 
been no defect in health. Organic disease of the sensory centers, 
or paths, in the brain and cord are responsible for nearly all 
the rest. 

It is usually strictly and limitedly local, but may be general, 
and it is more common in hairy parts and in women. There is 
nothing to be seen; there is simply spontaneous pain, constant 
or intermittent, and of all grades of severity; it is of a superficial 
character, and accompanied by more or less hyperesthesia, 
though firm pressure will sometimes relieve it; burning, prick- 
ing, shooting, or boring sensations have been met with by 
Duhring, and the pain is generally worse at night. The disease 
may last for an indefinite time, and even when apparently well 
is liable to relapse. 

This condition is distinguished from mere hyperesthesia by 
the pain being spontaneous, as well as easily excited, and more 
limited in area as a rule, and it is distinguished from ordinary 
neuralgia by its being superficial, and accompanied by hyper- 
esthesia. 

Causalgia, or the burning sensation symptomatic of the 
glossy skin, is an allied condition. 

Erythromelalgia. This was first described by Graves, and 
independently by Weir Mitchell in 1872, who gave it the above 



yi6 DISEASES OF THE SKIN. 

name, which means " red neuralgia." The leading symptoms 
are shooting, throbbing, and burning pains, more or less con- 
stant, with exacerbations of severity, especially when the foot 
is dependent, or on pressure, hyperalgesia being always present. 
The pain also is greater in hot than in cold weather. There is 
in addition a patchy redness when the limb hangs down, which 
is absent when it has been raised up for some time. Hyperi- 
drosis also is usually present. The lower limb, especially the 
foot, is chiefly affected, but the lower segments of the upper 
limb may also be involved, and it has attacked the face. It is 
now known that the condition is symptomatic of many forms of 
brain and cord disease, such as disseminated sclerosis, tabes 
dorsalis, neurasthenia, and myelitis. Pospelow's case was asso- 
ciated with Morvan's disease. It may also be due to peripheral 
neuritis. It is probably an angio-neurosis. In a woman of 
forty-nine, in whom these symptoms had been present a year, 
in consequence of prolonged worry, the pinky redness was lim- 
ited to the outer border and anterior two-thirds of the right 
sole. The first symptoms were terrible itching, followed by 
pricking, shooting, and burning, constant, but with exacerba- 
tions several times a day. She found some relief by soaking her 
foot in hot water, as it was dry and not moist as usual. Regard- 
ing it as peripheral, I ordered phenacetin gr. v. three times a 
day, which gave marked relief, especially to the burning, which 
was quite subdued. Most cases differ from the above in being 
aggravated by warmth. Morel-LavalleVs case lasted twenty- 
two years, the hands were affected with intense burning, and 
there was a slight degree of Raynaud's disease, an associated 
condition which has been met with several times. In a case of 
Eisner's gangrene extended to the foot. Weir Mitchell and 
Spiller in one case found intense degeneration of the peripheral 
nerves of the great toe, and thickening of the coats of the 
arteries and contraction of their lumen. In this and another 
case amputation of the part first affected gave relief. In a case 
of Eisner's erythromelalgia had existed in the left index from 
the age of sixteen. After twenty-three years of intense suffer- 
ing the finger became gangrenous and was amputated and she 
was cured. He thought this disease could not be separated from 
Raynaud's. 

Treatment of the other forms of dermatalgia must depend 



PRURITUS. 717 

upon the cause. Where no disease of the nerve centers or other 
definite reason can be found rheumatism is the probable source 
of the mischief; salicylate of soda or quinine may be tried, with 
vapor or Turkish baths, if it is widespread; but shampooing 
could scarcely be borne in the more localized forms. Beau 
recommends that the part should be blistered, but the better 
plan is to blister or apply a mustard leaf over the center from 
which emanates the nerve supply to the affected part. In all 
peripheral pain phenacetin and antipyrin are worth trying. The 
application of the menthol cone to the part would probably give 
temporary relief. In many cases the pain subsides spontane- 
ously in a few weeks. 



PRURITUS. 

Definition. — A functional defect of innervation, in which itch- 
ing is the only direct symptom. 

Much confusion arises from the terms prurigo and pruritus 
being frequently used as if they were synonymous. Here 
pruritus is used, not in reference to it as a symptom of a large 
number of skin diseases, such as eczema, urticaria, etc., but for 
those conditions in which the subjective sensation of itching is 
the sole symptom of the disease, though there may be sec- 
ondary lesions where the scratching has been very energetic, 
the signs of which have already been described under " The 
Scratched Skin " (p. 42). In the greater proportion of cases 
of general pruritus, although the itching is considerable, the 
secondary manifestations are absent, the skin appearing quite 
normal. In the majority itching is complained of, but some- 
times tingling, formication, or other modification of the sensa- 
tion is described by the sufferer, and while, in some cases, it is 
only a trifling inconvenience, in others it produces profound 
misery, less endurable almost than pain, and inducing such de- 
pression of mind as to result even in insanity. Bronson * argues 

*" The Sensation of Itching," by E. B. Bronson, New York Medical 
Record, October 18, 1890, and Reprint Syd. Soc. Selected Monographs in 
Dermatology, 1893. " The Pathology and Treatment of Pruritus." A 
Discussion at Annual Meeting of Brit. Med. Assoc, 1895, by McCall 
Anderson, Brooke, etc., Brit. Jour. Derm., vol. vii. (1895) p. 291. 



7 i8 DISEASES OF THE SKIN. 

that there is a special sense of contact apart from that of ordi- 
nary touch, and that pruritus is the result of disturbance of this 
sense of contact. 

Symptoms. — Pruritus may be general or local. In the general 
cases, Pruritus Universalis, the itching is not present all over 
the body at the same moment, but now one, now another part 
itches, and no sooner is it better in one place than it is worse 
in another. There are, however, great variations in duration; 
sometimes it is practically constant, at others there may be 
intervals of relief, but all cases are worse at night, where it 
pursues the patient even into his dreams, giving them what may 
be called a pruritic impress. 

Exposure, either to heat or cold, will generally excite it. 

In the local forms, although any part may be attacked, the 
genitalia and anus are the favorite regions, and hence we meet 
with the terms P. vulvae, scroti, and ani, as if they were special 
diseases; but the scalp and face are not very uncommon posi- 
tions, and in the latter it is felt chiefly about the nose and 
mouth. 

Occasionally the pruritis is localized to the palms and soles, 
or to the course of a nerve — c. g., I have met with an instance 
in an elderly woman in whom the pruritus was limited to the 
distribution of the sciatic, which was speedily relieved by the 
application of mustard leaves over the hip. 

In P. Vulvae the itching may affect the labia, vagina, and 
clitoris, individually or collectively, and is, in some cases, so 
constant and severe as to quite unfit the patient for all social 
duties, and it becomes, therefore, a very serious affection. 

In man the scrotum is the part most frequently affected, but 
the perineum and even the anus are often involved also; in a few 
cases the orifice of the urethra is the part attacked. 

Pruritus Ani is a very common affection in both sexes and 
at all ages, and is often so intense as to goad the patient to the 
most violent scratching; consequently, excoriations and more 
or less eczema and thickening are very frequent concomitants 
both of vulvar and anal pruritus, and bring their own aggrava- 
tion. The itching may be confined to the outside, or affect the 
inside also. Epithelioma may be developed from long-con- 
tinued scratching. 



PRURITUS. 719 

Etiology. — This is very important, as the success of the treat- 
ment depends upon its correct determination. 

General pruritus in the aged (P. Senilis) is a symptom often 
accompanying senile degenerative changes in the skin, and 
is sometimes especially intense in the " senile warts " previ- 
ously described. Probably the dryness of the senile skin is 
a predisposing cause, and in many persons who have naturally 
what is called an itchy skin there is a congenitally dry skin. 
In old people defective elimination from kidney and other 
degenerations plays an important part, and the cause may really 
be degeneration of the nerve-ends in some instances. In adults 
generally, always excluding such conditions as urticaria, pedicu- 
losis, and scabies, the most common cause is hepatic derange- 
ment, whether functional, as seen in the lithemia of Murchison, 
or organic, especially after ordinary jaundice, in which, inde- 
pendent of the cause, the itching is often very severe and per- 
sistent, though it seldom comes on before the jaundice has been 
present for some time or is declining. The next most frequent 
causes are disorders of the alimentary canal, such as dyspepsia, 
with or without constipation, " the gouty state," kidney diseases, 
such as albuminuria, chronic Bright's disease, and diabetes mel- 
litus. Ovarian and uterine disorders, and pregnancy sometimes 
originate it. In the last, when it has once been present, it is 
very likely to recur at any subsequent pregnancy. 

Depressing mental influences play a certain part in the eti- 
ology, and under this head may be included those cases in which 
the patients, generally of the better classes, have suffered, or 
imagine, on more or less good grounds, that they have suf- 
fered, from scabies or pediculosis, but whom nothing will per- 
suade that they are still not infected, however long and effectu- 
ally they may have been treated. Such cases of what might be 
called " pruritus mentis " are often on the borderland of in- 
sanity, and may end in actual melancholia. 

P. Palmes ct Plantcs is rare; it may occur either with or with- 
out hyperidrosis. Many of the patients are gouty; in women 
it is occasionally seen in association with uterine disorders. 
Some drugs and foods would sometimes produce itching in 
some persons with special idiosyncrasy. Season has a certain 
influence in some cases; some patients suffer from itching in 
summer only (P. cesHvalis); others in winter (P. hiemalis), on 



7 2o DISEASES OF THE SKIN. 

which Duhring * and Corlett f in America, Hutchinson in Eng- 
land, Obersteiner in Austria, and Dubreuilh J in France, have 
written papers. They consider it a distinct affection; it may be 
general, but usually is confined to the lower extremities. I have 
met with a few instances. One patient, a plumber, set. twenty- 
nine, had suffered every winter for six years, the pruritus being 
general, lasting as long as the cold weather. There were no 
objective signs, and no evidence of lead-poisoning or gout, ex- 
cept that his urine was frequently loaded with lithates. Sulphur 
baths gave him most relief, but internal medication had but 
little effect. In another case it had existed from boyhood, 
though his skin was moist. In children itching of the thighs 
and legs is often experienced in cold weather. The skin is 
slightly red and rough. The affection is really a slight eczema. 
Xerodermatous children are especially liable to it. 

Local Pruritus is often dependent on a local cause. Pruritus 
vulvae in children is generally due to ascarides in the rectum, 
and sometimes in the vagina itself. Other causes of irritation 
of the lower bowel, such as catarrh, scybala, etc., may also pro- 
duce it. In adults it may be due to uterine or ovarian derange- 
ments, functional or organic, or be a concomitant of vaginitis 
and urethritis, and is often present only at, or much aggravated 
just before or during, the periods; but it is still more frequently 
present as one of the neuroses to which women are liable at the 
climacteric age. Diabetes mellitus is a frequent cause, chiefly 
in middle life, but in all cases the urine should be tested, eczema 
vulvae being then invariably present also; indeed in all cases 
eczema is a cause or consequence. Sometimes pruritus vulvae 
has developed on pruritus ani, and is then due to the same cause 
as that affection. 

Pruritus ani in an adult is in nearly all cases due to hepatic 
derangement, and the hemorrhoids which are so frequently 
present are the consequence of this derangement and at the 
same time produce local aggravation of the itching; the same 
may be said of constipation and fissures. Decomposition of the 
sweat in those who perspire freely is another source of irritation. 

* Duhring, Phil. Med. Times, January 10, 1874, 

f W. F. Corlett, " A Clinical Study of Pruritus Hiemalis," A7ner. Jour. 
Cut. Bis., vol. ix. (1891), p. 41. 

X Dubreuilh, '*' Prurigo hivernal," y<?z/r. de Med. de Bordeaux, February 
8 and 15, 1891. 



PRURITUS. 721 

In gouty people pruritus ani is often one of their first warnings 
that they are going wrong. Both P. ani and of the pudenda in 
both sexes may also be due to pelvic tumors obstructing more 
or less the pelvic veins and inducing, therefore, a local con- 
gestion. 

In children ascarides in the rectum, or tapeworm, or lumbrici 
higher up, or mere catarrh of the intestinal canal may be the 
causes of anal or nasal itching, as may often be observed in 
rickets. 

Pruritus Scroti and of the pudenda generally in men is not 
common, except as the result of eczema, which is not necessarily 
very pronounced. 

Itching at the end of the penis may be caused by stone or 
other irritant at the neck of the bladder. 

Pathology. — As already intimated the disease is a sensory 
neurosis, due to a direct or reflex irritation of any part of the 
nervous system, from the center to the periphery of the part 
affected, and not accompanied by any appreciable lesion of the 
skin nerves, but the presence of epithelium appears to be essen- 
tial, as in the familiar instance of wounds which do not itch 
until epithelium appears. 

Diagnosis. — This resolves itself into the diagnosis of the 
causes of the itching, and familiarity with the etiology is there- 
fore essential. As a matter of practice, when a patient com- 
plains of general pruritus, the first thing to do is to exclude 
parasitic irritation, whether of bugs, fleas, gnats, lice, the itch 
acarus, or harvest bug, etc.; nine times out of ten, however, the 
parasite is the pediculus in an elderly person, or the scabies 
acarus at any age. The position of the scratch marks will go 
a long way towards deciding this; if they are about the 
shoulders to any extent, there is a strong presumption in favor 
of pediculosis; if about the hands or wrists, of scabies. The other 
points of diagnosis of these diseases are described under their 
respective heads. The next most common disease is urticaria, 
and unless the patient is a child there will very probably be no 
objective symptoms at the time of examination; the patient's 
answer to the. question as to whether he "comes out in bumps 
as if stung with a nettle " will settle this point, though it has 
still to be determined whether the urticaria is the primary cause 
of the itching, or only the consequence of the scratching. These 
46 



722 DISEASES OF THE SKIN. 

three diseases being excluded — and it is only in one or other 
of them that the so-called " pruritic rash " is very marked — 
investigations into the presence of any hepatic, digestive, or renal 
disorder must be successively investigated, the urine in all cases 
is to be tested, and but few cases will remain that are not refera- 
ble to one or other of these systems. If the patient is ad- 
vanced in years, and every other source of itching can be ex- 
cluded, then, and not till then, the diagnosis of senile pruritus 
remains as a refuge, but it must be borne in mind that there 
may be defective elimination without the physical signs of 
albuminuria, etc. When the pruritus is local a careful examina- 
tion of the part must be made, to exclude any objective source 
of irritation, and the various causes enumerated under etiology 
reviewed, until the right one is found, or at least till driven to 
confess ignorance, after the most careful investigation has failed 
to reveal the fons et origo mail. 

Prognosis. — This is good or bad according to the success or 
failure in finding the cause, and the possibility of reaching or 
obviating it. 

Treatment. — This again depends upon the cause, and unless it 
has been discovered success is not very likely to attend aim- 
less therapeutic efforts. The internal treatment is both dietetic 
and medicinal, directed to the removal of any hepatic, digestive, 
renal, or uterine disorders that may be discovered. 

The diet should be bland and easily digestible; alcohol should 
be very sparingly taken, and is often best avoided altogether, 
and all condiments and sauces should be forbidden. 

The bowels in all cases must be carefully regulated; saline 
aperients are often required at first, and afterwards the bowels 
must be kept regular by extract of cascara sagrada, the com- 
pound liquorice powder, or other suitable laxative; as a rule, 
aloes should be avoided where the pruritus affects the anus or 
pudenda. Alkalies, especially bicarbonate and salicylate of 
sodium or of potassium, are generally required for icteric and 
other hepatic derangements; but it is unnecessary to go into 
further details, as the internal treatment is in accordance with 
the general principles of medicine in the treatment of the various 
disorders, and success seldom fails to attend judicious and per- 
severing efforts in the several directions indicated. There is, 
however, one empirical remedy that is sometimes of service,. 



PRURITUS. 723 

when either the cause is of an organic and irremovable kind, or 
where it cannot be ascertained. This is cannabis indica, first 
suggested by Bulkley for senile pruritus; five minims of the 
tincture are enough to begin with, but the dose generally re- 
quires to be increased up to twenty or thirty minims three times 
a day, well diluted, and after meals, or it will upset digestion; 
marked relief is generally experienced, and often complete cure, 
unless the original cause is still in active operation. It appears 
to act by diminishing cutaneous sensibility, and in a certain 
proportion of cases has acted very satisfactorily in my hands. 
He also recommends tr. gelsemii in ten minim doses, repeated 
every half hour until 5j has been administered, unless toxic 
effects show themselves. Hutchinson advocates vinum antim. 
tart., TTtv ter die in senile pruritus. I have known it relieve one 
case. 

Wannemacker has found lactophen fifteen grains three 
times a day relieve severe pruritus, but he is not able to point 
out when it is especially indicated. Hypodermic injection of 
one-tenth to one-third of a grain of pilocarpin is said to give 
as much as a day's relief from the pruritus of jaundice, though 
there may be a transitory aggravation. Antipyrin and phenac- 
etin are also sometimes successful, but all these empirical 
remedies are a confession of failure to ascertain or to eliminate 
the true cause of the pruritus. Whether the itching be general 
or local, especially of the anus, in some obstinate cases much 
benefit will be derived at an alkaline spa, such as Ems, Vichy, 
Contrexeville, or Harrogate; or where there is a necessity 
for laxatives, Carlsbad or Marienbad. The thorough flush- 
ing by large quantities of weak alkaline waters is often most 
efficacious. 

External treatment is always of value, and even when it does 
not affect the cause of the itching, by giving temporary relief it 
enables the patient to abstain from scratching, and this gives 
the irritated nerve filaments a chance of settling down, while 
internal or other radical measures are being directed to the 
origin of their trouble. For general pruritus lotions of various 
kinds are of service — at all events, for a time. The majority 
of them are of the disinfecting class, and it is always desirable 
to change them from time to time, if only to satisfy the mind 
of the patient, the mental attitude exercising an important influ- 



724 DISEASES OF THE SKIN. 

ence on the result. One of the best is the liq. carbonis deter- 
gentis SIj to aquae §viij, or the liq. picis alkalinus, in the same 
proportion, is almost equally good, or lysol oiss to gviij ; others 
are terebene §j to ^viij ; sanitas i part to 2 or 4 of water; carbolic 
acid 1 in 60; benzoic acid oij, aq. gviij ; thymol 3ij, liq. potass. 
3j, glycerin oiij, aq. o vn J> tn i s * s a ver > r good lotion; salicylic 
acid oij, sod. bibor. 5j, glycerin q. s., mix the acid and borax with 
oiv of glycerin, heat gently until dissolved, then add glycerin to 
make up 5j J this can then be diluted with glycerin, alcohol, and 
water to any extent, §j of the first compound, §j of alcohol, and 
water to o vn J> is a good proportion; it has the advantage of 
being free from smell, which is a drawback in the use of most of 
the others. Perchlorid of mercury gr. 1-2 to gr. 3 to §j of water 
is another good odorless lotion. Camphor chloral (equal parts 
of each constituent) gave great relief in a case of senile pruritus 
where the warts were the site of the itching; it may also be used 
diluted, by applying with a sponge to the itching surface. As a 
rule, lotions for senile pruritus should contain spirit, about one- 
quarter of spiritus rosmarini, eau de Cologne, or plain spirit, 
being added to one or other of the above anti-pruritic lotions, 
the evaporation and consequent cooling of the skin giving great 
relief. For this reason menthol gr. 2 to gr. 10 to the §j of water 
relieves this and other forms of pruritus. Chloroform 5j, glyc- 
erin 5iv, water gviij ; sodii sulphidi oij, glycerin §ss, water 
gviij; potassii cyanidi 5j to water Oj, are other formulae recom- 
mended on good authority. Baths are often very beneficial: 
alkaline with or without starch, bran, or gelatin, and sulphid of 
potassium, or the sulphaqua salts, are most frequently success- 
ful (see Appendix for formulae). Vapor and Turkish baths are 
worth trying. 

Static electricity was strongly recommended by Leloir for 
pruritus both general and local, the latter especially. The pa- 
tient is placed on an insulated stool, and is connected with one 
pole of a Wimshurst machine. The other pole with a metallic 
terminal is brought to four inches from the affected part. A 
brush discharge ensues which he says is not painful. The con- 
stant current has also been used in vulvar pruritus. Quite re- 
cently the high-frequency currents have been said to give speedy 
relief to local itching. 

For local pruritus special remedies are generally necessary; 



PRURITUS. 725 

the number recommended as always giving relief testifies to 
the obstinate resistance to medication frequently offered. 

Pruritus Scroti is often best relieved by painting on argentic 
nitrate gr. 10, sp. aetheris nitrosi 5J. The unguentum hyd. 
amnion, gr. 10 or 20 to 5J is often useful here also. Boric acid 
lotions are good in many cases. Bulkley's plan, as set forth for 
eczema scroti, gives several hours' relief; water, as hot as can 
be borne, being applied for five minutes at a time. 

Bronson's oil for local itching is liquor potassse oij, acidi car- 
bolici oiv, ol. lini ad gij, ol. bergamot T^x. 

For Pruritus Vuk'cc strong lead lotion, oij or oiv to 5viij, is 
a good one; or nitrate of silver gr. 5 to 10 to §j of nitrous ether 
is one of the best applications; the stronger lotions are used at 
intervals of a couple of days, but they stain both skin and linen. 
A saturated solution of boric acid answers well in many cases; 
Neale thinks it one of the best remedies. Pixene is strongly 
recommended by Locke, oij to §vj of water with gss of glycerin; 
but the best of all, in my opinion, is the plan recommended by 
Reeves, the compound tincture of benzoin, B. P., painted on 
with a camel's-hair brush every night. Where there is thicken- 
ing multiple scarification may be useful, and Unna recommends 
linear scarification with his micro-cautery. 

P. Ani. — Many mercurial ointments give immense relief for 
the time being. Ammoniated mercury gr. 20 to §j of benzoated 
lard is a favorite of mine. The yellow oxid of the same strength 
is often useful, and calomel gr. 10 to oss to *j is another good 
one; some combine with these carbolic acid gr. 10, creasote 
TTLxv, or camphor oss. The oleate of mercury, 1 or 2 per cent. 
with or without oleate of morphia, is often beneficial, but 
stronger applications must be used with caution; the diluted 
nitrate is another good application. Peruvian balsam, rubbed 
up with a little vaselin, is often successful. Sometimes ben- 
zoated oxid of zinc ointment, B. P., is better than anything if 
applied with strong pressure so as to temporarily empty the 
dilated veins. It should always be by the bedside to apply in 
mitigation of damages when the patient has yielded to the 
temptation to scratch. Ichthyol as a 5 per cent, lotion or a 
10 per cent, ointment or soap has many friends. 

Morris strongly recommended cocain as successful in one 
obstinate case, and others have spoken well of it, but it has not 



726 DISEASES OF THE SKIN 

helped me much. It would be most likely to succeed when a 
starting point of the pruritus can be localized. Extract of bella- 
donna gr. 1-2 to gr. i, in the form of suppository at bedtime, 
often enables a patient to get off to sleep before the torment 
comes on; morphia may be added, or given alone. In all cases, 
especially in those who perspire freely, ablutions with carbolic 
acid i in 60, saturated solutions of boric acid, and 1 in 4000 
perchlorid of mercury, lysol oiss to o vu J> or with permanganate 
of potash lotion, are necessary, and of themselves often give 
relief. If there are external piles, the old unguentum gallae is 
often useful for both the piles and pruritus, but painting with 
hazeline or injections of it are better. These are a few only of 
many local remedies, but though all are more or less tem- 
porarily useful, the mercurial ones are generally the most suc- 
cessful; but permanent relief is only to be obtained by the treat- 
ment suitable for the etiological factor. 

The mineral spas of Contrexeville and Ems, or, if aperients 
are required, Carlsbad and Marienbad, are often of signal service 
in pruritus ani. 

In spite of this extensive armamentarium successful treat- 
ment is often very difficult, though few cases are absolutely 
incurable. 

ANESTHESIA. 

This affection comes under the notice of the neurologist more 
than that of the dermatologist. 

There are all grades of it, from only slight diminution of 
sensibility up to complete loss of sensation to the strongest 
impressions. It may be general or local, unilateral or sym- 
metrical, hemiplegic or paraplegic, limited to a single nerve 
domain or affecting several; there may also be analgesia, with- 
out loss of tactile sensibility, as in syringomyelia, or intense 
pain with loss of ordinary sensibility (anesthesia dolorosa of 
Romberg), or both may be absent together. Like the other 
sensory neuroses it is chiefly interesting from an etiological 
point of view. It may be idiopathic or symptomatic, and de- 
pendent on internal or external causes. The internal causes are 
either in the sensory nerve centers, or at some point where the 
sensory path from the periphery to the center is interrupted, 



ANESTHESIA. 727 

£. g., unilateral lesions of the brain surface or the parts ad- 
jacent, locomotor ataxy, traumatic disease of the nerves, 
syphilis, leprosy, or tumors pressing on a nerve trunk. In 
leprosy the function may be disturbed by either nerve trunk 
lesions or peripheral clogging, so to speak, with leprous 
infiltration. 

Hysterical anesthesia is not uncommon, and is unilateral, but 
not always on the same side, changing about under mental in- 
fluences in the most extraordinary way. Of external causes, 
cold, however applied, carbolic acid, caustics, cocain, chloro- 
form, aconite, pressure on a nerve, e. g., the ulnar, are the most 
common; while of drugs given internally, chloroform, ether, 
nitrous oxid, and other anesthetics, cannabis indica, alcohol in 
excess, lead, and opium may be mentioned. 

The treatment entirely depends upon the cause and its amena- 
bility to medical measures. 



CLASS VIII. 
NEOPLASMATA— NEW GROWTHS. 

This is a large, important, and somewhat heterogeneous 
group, of which the main feature is a growth or infiltration of 
new elements in the skin. It may be subdivided into: 

1. Degenerative neoplasms, or such as are characterized 
by the presence of marked degenerative changes, compris- 
ing molluscum contagiosum, colloid of the skin, and xan- 
thoma. 

2. Infiltrative, in which the neoplasm consists chiefly of in- 
filtration of granulation cells in the cutis, comprising such dis- 
eases as tuberculosis, syphilis, lepra, and rhinoscleroma. They 
are all of schizomycetic origin, though the organism of 
syphilis has not yet been identified. It is probable that Ka- 
posi's idiopathic pigmented sarcoma really belongs to this 
section. 

3. Tumors of benign nature, such as keloid and fibroma af- 
fecting the connective tissue; neuromata involving the nerve 
tissue; myomata, the muscle tissue; naevus vascularis and telan- 
giectasis, the blood-vessels; lymphangiectodes and lymphangi- 
oma, the lymphatics; and to these moles may be added, as, like 
most of the others, they are of congenital origin. 

4. Tumors more or less maligannt in their characters and 
course, comprising carcinoma, epithelioma, rodent ulcer, Paget's 
disease of the nipple, sarcoma, leukemia, and pseudo-leukemia 
cutis. 

5. Fungating granulomata, including mycosis fungoides, 
yaws, verruga peruana, furunculus orientalis, ulcus inguinale 
tropicum, granuloma pyogenicum. Several of these are con- 
tagious, and all except mycosis fungoides are certainly of 
microbic origin, and that disease also is probably due to an 
organism either directly or indirectly. 

728 



MOLLUSCUM CONTAGIOSUM. 729 

MOLLUSCUM CONTAGIOSUM.* 
Deriv. — Molluscum, a mollusc, from mollis, soft. 

Synonyms. — Molluscum sebaceum; Molluscum sessile; Fr., Acne 
varioliforme (Bazin); Molluscum verrucosum (Kaposi). 

Definition. — Small sessile or pedunculated, glandlike tumors 
of a pearly white or pinkish color, which are formed in the rete. 

This disease is not very common in England, and it appears 
to be quite rare on the Continent and in America, though it is 
doubtless more common than dermatologists' statistics suggest, 
2 in 1000 in my practice. It is common about the genitalia of 
prostitutes and of those who cohabit with them, and is very 
likely to be aggregated into masses on the thighs. 

Symptoms. — The tumors are nearly always multiple, varying 
in number from two or three up to many scores, and in size 
from a small pin's head to a large pea, the average being one- 
eighth of an inch. They are of firm consistence, nearly 
hemispherical in shape, but flattened on the top and usually 
umbilicated, while in the larger ones there is a small central 
hole, leading to the interior of the tumor, through which milky 
fluid or a solid waxy mass may be expressed. At first they are 
sessile, pearly, or waxy-looking, but as they grow larger the 
contents become more opaque and yellowish, while the skin 
over them is of the normal hue unless from vessels coursing over 
them, and they may become more or less pedunculated. They 
are usually discrete, and the commonest positions are the face, 
neck, scalp, breasts, and genitalia. They may form anywhere, 
but are very rare on the palms and soles.f They begin as only 
just perceptible elevations above the skin, grow slowly, and 
after attaining to their full size may remain unaltered for a long 
time, or they may inflame, suppurate, discharge their contents, 
and disappear, perhaps without leaving even a scar. 

Hutchinson says that in a month or two they disappear 

* Author's Atlas, Plate LVII., Figs. 1 and 2 ; the last shows a suppurat- 
ing tumor. Sydenham Society's Atlas, Plate XL VI., on face and breast. 
Kaposi's Hand Atlas, Plate 226, on the penis and scrotum. St. Louis 
Atlas, Plate XLII., on the vulva. 

f Balzer and Alquier record a case on the sole. Annates de Derm., 
vol. i. (1900), p. 528. 



730 DISEASES OF THE SKIN. 

spontaneously, but this much understates the duration. (Vide 
Prognosis.) 

Variations. — A few cases of molluscum giganteum are re- 
corded by Hebra, Virchow, Laache,* Walter Smith,f and E. 
Wilson respectively. In Laache's case the tumor was single, 
grew from the occipital region, and was the size of two fists; 
but the microscope proved that it was a molluscum contagiosum. 
Confluent molluscum without much elevation is rather more 
common. In a case of Hallopeau's there were plaques on the 
back of the left calf, the largest two inches by one and a half, but 
raised up only one-eighth inch.J C. Fox showed a case to the 
Dermatological Society in May, 1902, an elderly woman; on the 
right temple was a cribriform mass formed by aggregation of 
tumors, each about the size of a hazel nut. There were some 
of the usual size and character near and in other parts, but some 
of the larger tumors had no central orifice, and had vessels 
coursing over them, so that by themselves they would not be 
recognizable. White opaque fluid could be squeezed out of 
those with an orifice. Another form that I have seen is the very 
opposite of this; on the back of the wrists and over the knuckles 
of the left hand, in a woman, set. eighteen, were congeries of 
tumors from a pin's head to a hemp seed in size, the larger 
tumors being generally compound. They were distinctly raised 
above the surface, obtusely conical, with a flat top, of a violet 
hue due to dilated vessels at the periphery, while the central 
part was of a yellowish-white color, due to a friable plug, which 
could be squeezed out with moderate pressure, while the whole 
contents could be evacuated with strong pressure. In the com- 
pound tumors there were two or three plugs, while in the scat- 
tered ones, of which there were a few on the back of the right 
hand, and also upon the face and the angle of the mouth on the 
right side, there was only one such plug. A small piece of skin 
containing three small tumors was excised, and microscopical 
examination showed it to be of molluscous structure, with a 

* Abstract in Amer. Jour, of Cut. and Ven. Dz's., February, 1885, p. 64. 

f In W. Smith's case the tumors were very numerous and general, and 
one was three inches and a quarter by three inches. Dub. Jour, of Med. 
Science, November, 1878. He also quotes E. Wilson as having had a case 
where the tumor was three and a half inches in diameter. 

% Annates de Derm, et de Syfth., vol. x. (1899), p. 134, quotes cases of 
Alibert, Vidal, and Kaposi. 



MOLLUSCUM CONTAGIOSUM. 



73i 



single, flat, flask-shaped, acinus-like downgrowth of the rete, 
containing a plug of altered rete cells like molluscum bodies, 
while there was slight leukocytic infiltration in the corium round 
the tumor. Some of the growths were touched with the acid 
nitrate of mercury; a vertical incision was made into the rest 
and the contents squeezed out, and there was no return of them. 




Fig. 34.— Peculiar form or molluscum contagiosum with a single acinus, 
formed from an outgrowth of the rete mucosum, with central plug of 
molluscous material. 



A peculiar case, with many of the characters of molluscum 
contagiosum, but also with many differences, is recorded by 
Payne.* There were in the papules bodies structurally like 
psorosperms, but they were really altered epithelial cells. 

Etiology. — They are much more common in children than in 
adults, in the poor than in the rich, and it is said, in females 
than in males. Most English authorities agree that the tumors 

* Brit. [our. Derm., vol. iii. (1891). p. 250. 



732 DISEASES OF THE SKIN. 

are contagious, while in Germany * and in America f the con- 
tagious theory is not so generally accepted. There are many 
cases where prolonged contact has apparently imparted the dis- 
ease, c. g., mollusca appearing on the face of the sucking infant 
and on the breast of the mother, and it is not a rare event to 
meet with several cases J in the family. The failure to convey 
the disease by artificial inoculation does not prove that it is non- 
contagious, as many vegetable parasitic diseases, admittedly 
contagious, cannot be propagated at will; while Patterson, Ret- 
zius, Vidal,§ Stanziale, Pick, Haab, and Nobl have been success- 
ful in their inoculations, || though with many failures. In Pick's 
two cases the first sign of the lesion took ten weeks to manifest 
itself, and Nobl's was nine weeks before they were distinctive. 

Turkish baths fl are said to produce the disease, but they 
merely offer favorable conditions for the contagium. 

Salzer ** records the case of a lady with molluscum contagi- 
osum, in which it seemed probable that she had contracted it 
from pigeons which she was in the habit of feeding. The birds 

* Caillaut relates that in a children's ward of thirty beds, fourteen were 
affected with this disease, which began from a single case (" On Diseases 
of the Skin in Children," second English edition, p. 78). 

t Mittendorf of New York has reported two extensive outbreaks in asy- 
lums for children. Allen also records fifty cases in a children's asylum. 
Stelwagon and Graham have also reported outbreaks. 

\ See Duckworth's paper on cases favoring the contagious theory (St. 
Bart.'s Reports, 186S, p. 211). 

§ Model 515 in the St. Louis Museum, showing a successful inoculation 
on an infant's arm. 

|| Stelwagon, Join-, of Cut. and Gen.-Ur. Di's., vol. xiii. (1895), p. 50, 
" The Question of Contagiousness of Molluscum Contagiosum," gives 
full references. 

Tf I have seen several such cases : one, a gentleman, had numerous 
mollusca on the nape and back of the poll, where it had been in contact 
with the wooden head-rest at the Turkish bath ; in another, a lady, many 
scores of translucent pearly mollusca were scattered all over the back ; 
she had lain on the felt-covered benches without any intervening cloth. 
In the third, a lady who took a Turkish bath every other day, but in her 
own house, the mollusca were numerous on the trunk and arms. The skin 
on and round the tumors was red, and they were pruritic. The source of 
infection was her own son, who said that many of his schoolfellows had 
similar " warts." Hutchinson says that all his male cases were frequenters 
of the Turkish baths; he suspects the towels or gloves. 

** Munch, med. Woch., September 8, 1896, p. 841. Abs. Brit. Jour. 
Derm., vol. ix. (1897), p. 173. 



MOLLUSCUM CONTAGIOSUM. 733 

died of an epidemic disease which produced emaciation with 
growths on the beak, said to be epithelioma contagiosum of 
fowls. Hutchinson has recorded a case in which a woman con- 
tracted the disease from her dog; in the latter it was proved 
microscopically. Shattock * has observed it in bunting. 

Pathology. — It is now generally agreed that the lesions 
are derived from the prickle cell layer of the epidermis 
by the accumulation of altered epidermic cells, and the 
hyperplasia produced by the irritative presence of these 
cells or the original hypothetical infective organisms. The 
nature of the degenerative change which produces " the 
molluscum body " has been disputed hitherto. The idea 
that it was hyaline or colloid gained most support; but 
Charles J. White, the most recent observer (April, 1902), states 
positively that it is " normal keratin," thus confirming Piffard's 
observation that these bodies react to polarized light like 
corneous epithelioma. The change may start in the cells of the 
hair follicle as well as in the rete independent of them, but the 
old view, that the tumors are metamorphosed sebaceous 
glands, has scarcely any supporters. The organism which 
produces the change is still undiscovered. The psorosperm 
theory was soon exploded. 

Anatomy. f — When a vertical section is made through the center of a 
small well-developed tumor, it is seen to consist of wedge-shaped lobules, 
all converging towards a common center, the central being the smaller 
end ; between each lobule is a very thin fibrous septum, and the whole is 
inclosed in a fibrous capsule, incomplete above, with its base in the corium. 
While the border is continuous with the epidermis, each lobule is bounded 
by palisade epithelium, and round, nucleated epithelium lies adjacent, 
but even in many of the lowest cells, the molluscous degeneration has 
commenced. This consists of a change which renders the cell substance 
opaque, white, and homogeneous, like amyloid degeneration, and this 
gradually encroaching on the cell substance ultimately fills up the cell, 
enlarging it, obliterating its structure, and making it quite homogeneous, 
and it is then the so-called " molluscum body." These bodies accumulate 

* Shattock's paper on Avian M. Contagiosum should be referred to, Path. 
Traits., vol. xlix. (1898), p. 394. 

f "Unna's Histopathology," p. 794. Unna is strangely in error in class- 
ing me among those who do not believe in the origin of the change in 
the prickle cell layer. Though I do think it can be proved to start in 
many growths in the prickle layer of the hair follicle. I stated in my 
1893 edition that it also arises in the rete, apart from the follicles. 



734 DISEASES OF THE SKIN. 

at the mouth of the lobule, and with those from the other lobules form a 
yellowish mass, which does not stain with carmine or other dyes, and the 
horny layer over it giving way, some of this mass often falls or is squeezed 
out, and the hole that is usually described at the mouth of the follicle is 
formed. The resemblance to gland structure is very complete, and the 
old view was that the tumor was merely an enlarged and changed seba- 
ceous gland. 

Virchow first put forward another view, viz., that the disease is in the 
Malpighian layer, and he thinks that the disease begins in the hair follicles ; 
the observations of Boeck, Lukomsky, Piffard, Sangster and Thin, etc., 
confirm this view, and I can indorse it for some tumors, but it is only by 
examining them in the early stage that this can be made out. Another 
proof that they are not sebaceous gland structures is that they have been 
observed on mucous membranes (Colcott Fox and Abraham on the 
tongue). 

The following description is from my own observations: Taking 
a tumor at the earliest period recognizable, when it is only about the 
size of a pin's point, a vertical section shows the molluscum bodies accu- 
mulated in a small mass at the top of the rete; and in the granular layer, 
below this, there is only a partial change in the rete cells, and it gets 
gradually less until they are quite normal, or only a very few of them 
adjacent to the boundary of the palisade cells are affected; the inter- 
papillary processes are already enlarged, both vertically and laterally, and 
the papilla is thus narrowed and elongated, but as yet there is no sign of 
glandlike structure. The most striking feature is the small accumulation 
of altered cells at the surface, and it is evidently a rete change. Many 
sebaceous glands and hair follicles are quite healthy, but in some of the 
hair follicles the cells present the same alteration, the process being 
always most advanced close to the shaft (Fig. 36). Taking next a tumor 
slightly more advanced, as in Fig. 35, it is found to consist of wedge- 
shaped lobes separated by a fibrous septum, formed by the compressed 
papilla, elongated by the continued downgrowth of the rete; in the center 
of the tumor are molluscum bodies, compressed above, so that the outline 
of the component cells is indistinct or lost, and if the section has been 
made through the center of the tumor, the rete is seen to be continuous 
from the surface to the deepest part of the tumor, forming a flask-shaped 
depression, bounded by the palisade cells, giving the appearance of the 
formation being due to an inversion of the whole epidermis, and the 
fibrous septa are the obliterated papillae. Thin considers that the mollus- 
cum change commences in the cells of the upper layers of the rete; Cam- 
pana, that it begins in the stratum granulosum; I think it begins at the 
deep part of the rete, and increases as the cells progress to the surface; 
while Lukomsky asserts that molluscum bodies are derived from 
leukocytes. 

The change in the rete cells which results in the formation of the so- 
called " molluscum bodies" is, according to Torok and Tommasoli, a 
hyalin or colloid change, and Unna says that it only occurs in the central 
portion of the prickle cell, while the normal keratinization takes place at 



MOLLUSCUM CONTAGIOSUM. 735 

the periphery. The latest observations are those of Charles White,* who 
has made a careful examination by modern methods, but, from the con- 
text, apparently not on the smallest tumors. Like myself and others, he 
found the change increasing from below upwards. The septa between 
the component lobules of the tumor consist of keratin. There was an 
empty perinuclear space in the Malpighian and granular cells, and in- 
flammatory reaction round the tumor with colloid (?) degeneration. The 
molluscum bodies, he was satisfied, consisted of normal keratin. His co- 
worker, Robey, could find no organism except the staphylococcus epider- 
midis albus of Welch, and they express the opinion that so far it is undis- 
covered, and in my opinion it never will be found unless the earlier 
stages are investigated. 

Diagnosis. — The small sessile or slightly pedunculated, solid 
tumors, with their central depression, once seen, would scarcely 
be mistaken, but when numerous and pearly they are very 
like vesicles, such as those of varicella. In exceptional cases 
it may also simulate other eruptions ; thus Abraham f met with 
a case where some of the lesions were very like lichen planus; 
Pringle, J where some of them on the scalp were like a 
rodent ulcer, and Kaposi's case § was like a bromid eruption, 
and this it probably was. A fungating growth at the angle of 
the mouth of a boy was referred to me as a possible chancre, 
but there was no adenitis, and a small characteristic lesion was 
found on the chin. The difficulty can generally be got over by 
a careful examination of all the lesions, when probably some 
would be characteristic, and the molluscum bodies could be 
found by the microscope. In the varicella-like form, the dura- 

*" Molluscum Contagiosum," by Charles J. White and William H. 
Robey. Reprint from Journal of Medical Research, vol. vii., No. 3, 
April, 1902, pp. 255-277. References to date and general review. White 
follows Unna in misrepresenting me as a believer in the glandular origin 
of the tumor. 

f Abraham, Brit. Jour. Derm., vol. xi. (1899). 474. The tongue was 
affected, simulating large patches of leukoplakia, but really made up of 
of papules. 

^Pringle, Brit. Jour. Derm., vol. x. (1898), p. 418. 

§ Kaposi, Annates de Derm, et de Syph., vol. vii. (1896), p. 1385. Rep. 
Vienna Derm. Soc. and Plate 226 of his Hand Atlas. The patient was a 
suckling, aet. six months. The eruption was very extensive, had been de- 
veloping for six weeks, and fresh attacks appeared in a few hours. The 
lesions were exactly like those of bromid. Examination for molluscum 
bodies was negative except on a lesion on the throat. Bromids are so 
frequent in quack medicines that a negative history on the mother's part 
does not count for much. 



736 



DISEASES OF THE SKIN, 



tion and the effect of pricking, which would show them to be 
solid, would prevent error. 

Prognosis. — While no doubt cases do sometimes get well 
spontaneously, it is usually much more than the month or two 




Fig. 35. — Section through the center of a very small tumor of molluscum 
contagiosum just perceptible to the naked eye. X 125. 

a, rete mucosum continuous with the tumor; &, plug in center of tumor 
formed by an accumulation of molluscum bodies; c, cells of the rete 
in process of conversion into molluscum change; d, d, cells in an 
earlier stage of conversion into molluscum bodies; g, pseudo-lobe of 
tumor formed by vertical and lateral growth of the interpapillary 
processes;/", fibrous septum between lobes of tumor formed by com- 
pression of papilla; e, sebaceous gland of small hair follicle. 

mentioned by Hutchinson. I have had cases of nine, ten 
months, and more. Walter Smith's giant form dated back 
thirty years, and there had been no fresh ones for fifteen years 
or more. Another case in his table was one and a half years. 
The short duration of the majority of the cases is probably ac- 
counted for by the fact that advice would be sought in most 
cases as soon as the lesions became conspicuous. 

Treatment. — This is simple and effectual. The tumor should 
be split from below upwards with a sharp knife, and pressure 
being made at right angles to the incision with the thumb nail 
and handle of the scalpel, the contents are readily evacuated; 



XANTHOMA. 737 

rather free bleeding is easily stopped by a pad of lint. Some 
recommend that the interior should be touched with nitrate of 
silver, but it is unnecessary; others dispense with the incision, 
but this is almost painless, and the extra pressure required to 
empty the tumor without it gives much pain. Very small 
nodules may be touched with the end of a match dipped in the 
acid nitrate of mercury or ethylate of sodium. 

These or similar applications should be used for very young 



- — w 




Fig. 36. — Transverse section of a hair follicle in an early stage of mol- 

luscum contagiosum. X 550. 

a, a, epithelial cells showing molluscum change. 

children, for while the pain of expressing them is slight for an 
adult, it is serious for the young, especially when the lesions 
are numerous. Hallopeau recommends tincture of iodin to be 
introduced into the tumor by the pointed end of a match. The 
tumor dries up and shells off more quickly if some of the 
contents are squeezed out before the iodin is introduced. 

XANTHOMA.* 

Deriv. — gavOoS, yellow. 

Synonyms. — Xanthelasma; Vitiligoidea; Molluscum choleste- 
rique (Bazin) ; Fibroma lipomatodes (Virchow). 

Definition. — A fibro-fatty neoplasm forming yellow plates or 
nodules in the corium. 

Xanthoma is not a common disease under any circumstances, 
but the cases in which it is limited to the eyelids (X. pal- 
pebrarum) are much more frequently met with than those 

1/1 Literature.— Author's Atlas, Plate LVIII., illustrates palpebral, nod- 
ular, and congenital forms. St. Louis Atlas, Plate VIII., illustrates X. 
47 



738 DISEASES OF THE SKIN. 

where the lesions are more generally distributed (X. multiplex). 
Most of this latter form are of congenital origin in the young, 
and connected with jaundice or glycosuria in adults. 

It occurs in two forms, in plates (X. planum), and in nod- 
ules or tumors (X. tuberculatum or tuberosum) ; they repre- 
sent little more than differences in position, shape, and degree 
of development. 

Symptoms. — Xanthoma palpebrarum constitutes the great 
bulk of the cases, and is almost always in plates. It usually 
commences on the internal canthus of the left upper eyelid, and 
by the gradual coalescence of several patches sometimes forms 
a semicircle round the eye. Sooner or later similar patches 
appear on the right side, the disease being always symmetrical 
if it has been present long enough, though the left side is 
naturally more advanced in development. The plates are im- 
bedded in the corium, very slightly or not at all raised above 
the surface, of a chamois-leather-yellow color, which becomes 
more distant when the skin is stretched, of irregular outline, 
but tending to be elongated, from about an eighth of an inch to 
one inch in their long diameter, quite soft and smooth to the 
touch, and the skin does not seem thickened when pinched up. 
With a lens the patches can often be seen to consist of an 
aggregation of small yellow granules, which usually have a 
central pinkish punctum. 

The nodules are of the same color as the plates, project 
more or less above the surface, and as a rule are from a millet 
seed to a large pea in size, but may even be as large as a small 
apple. The small ones are convex, roundish, or oval, often 
have fine tufts of vessels over them, and are quite soft and 
smooth to the touch. The larger tumors, being compounded 
from the smaller ones, are irregular in contour and of more or 
less firm consistence, according to the amount of connective 

planum in large plaques. It is not a case of X. diabeticorum, though 
glycosuria was present. Pye-Smith, Guy's Hospital Reports, 1877. 
Hutchinson, " Clinical Report on Thirty-six Personal Cases of X. palpe- 
brarum," Med. Chir. Trans., vol. liv. (1871), p. 171 (some of the state- 
ments require some modification in the light of further experience). 
Gendre, "Paris Thesis on Xanthelasma," 1880. Report of Xanthoma 
Committee of the Path. Soc. on Startin's and Mackenzie's cases, vol. 
xxxiii. (1882), p. 376. In the same volume is a very complete resume oi 
the clinical facts up to that date, with tables of X. multiplex cases. 






XANTHOMA. 7 39 

tissue they contain. Unless there is jaundice present, the 
skin round and between both nodules and plates is quite 
normal. 

X. multiplex in the adult is most frequently associated with 
jaundice of long standing, and the lesions are both in plaques 
and nodules. Its distribution may be very wide, affecting not 
only the skin, but also the mucous and serous membranes and 
the tendons. The most common positions are the eyelids, 
where it generally commences, the palms and soles and backs 
of the hands and feet, especially the knuckles, the elbows, knees, 
buttocks in and near the cleft, and round the anus, and the 
flexures generally. 

The plaques are most frequently found on the eyelids, 
flexures, and mucous membranes, and the nodules on the 
extensor aspects, especially on parts exposed to irritation, like 
the knuckles, elbows, and knees. Symmetry is observed in 
multiple as well as in eyelid cases, and the limbs are much more 
involved than the trunk. 

As a rule, the disease gives rise to no inconvenience except 
from its disfigurement or position; sometimes, however, burn- 
ing, pricking, or itching has been experienced, and occasionally 
the sight has been interfered with by the new growth overhang- 
ing the eye, or by its size interfering with the movement of the 
eyelids, and when it is on the palms or knees, grasping or kneel- 
ing may be attended with discomfort, or even pain. 

In most instances the lesions appear gradually, and increase 
slowly by aggregation; then, after months or years, develop- 
ment ceases, and there is no further alteration; in three in- 
stances, however, involution has spontaneously occurred after 
several years, without any pigmentation or scarring being left, 
and in one other case, apparently as the result of treatment. 

Variations. — The plane form may be seen in lines or striae, 
especially in the flexures and on the palms and soles; in papules 
and macules as well as in plaques, and accordingly some 
authors give names to all these forms, such as X. lineare vel 
striatum, X. maculatum et papulatum, representing for the 
most part early lesions of which the patches are formed. Then 
some would make a X. tuberculatum for the smaller and 
X. tuberosum for the larger tumors, but these are un- 
necessary refinements. The color is not always like chamois 



74o 



DISEASES OF THE SKIN. 



leather; it may be of any shade of yellow, from yellowish-white 
upwards, and a certain amount of blackish pigment may, in 
rare instances, be seen in the lesions. Abercrombie showed 
me a case at the Charing Cross Hospital due to jaundice, in 
which, along with the ordinary lesions, the front of the neck 
and lower lip formed one large area of a dirty, slightly yellow- 
ish-white color. There was no perceptible elevation or thicken- 
ing of the skin, but the natural depressions were exaggerated 
like orange peel. The less common positions for X. multiplex 
on the skin are the ear, neck, back, and chest; in Hardaway's 
case the lesions were distributed like zoster over the ninth and 
tenth rib-spaces of the right side, the prepuce, glans, and other 
parts of the penis and scrotum, and under the nails. It has 
been observed on the mucous membranes of the cornea and 
conjunctiva, the sides of the tongue, the angles, roof, and floor 
of the mouth, the palate, pharynx, larynx, trachea, bronchi, 
esophagus, capsule of the liver and spleen, the peritoneum, 
round the rectum, the lining of the bile ducts, and the inner 
coat of the arteries and on the sheaths of tendons, such as the 
Achilles tendon and those of the extensor aspect of the fingers. 
Then the lesions may first appear on, and even be restricted to, 
unusual positions, such as the outer canthus, the cheek, the 
side of the neck, nates, the root of the penis, and the heel and 
soles; and X. multiplex has begun on the elbows, the flexures 
of the fingers and palms, and appeared on the eyelids subse- 
quently; in Robinson's case it came in a large patch on each 
elbow, and did not affect any other parts. This irregularity of 
distribution is more common in children and in congenital 
cases. In Kobner's case, a man, set. twenty-seven, on the 
other hand, the tumors were reddish-brown or reddish-violet, 
and situated in lines along the axillary folds and in the axillary 
region generally ; their color was due to their development in 
capillary nevi, of which there were a large number besides the 
X. nodules; it began when two years old, the mother said. Be- 
sides this association with vascular nevi, Kobner records a case 
which was associated with fibroma, and Hutchinson one with 
fusiform enlargement of many tendons. The case of Startin 
junior, a child, also had fibroid thickening round the joints, with 
xanthoma chiefly round the anal cleft and on the limbs. 

Children. — When the Xanthoma Committee published their 



XANTHOMA. 74 I 

report (1882), only eight * cases were known. Their statements 
were to the effect that cases before puberty are structurally the 
same as adult cases, but etiologically different, having no 
traceable connection with hepatic disease, but are in some 
cases probably hereditary, in some congenital; that the eyelids 
always escape, that the eruption is always multiple, and that 
there is a great tendency to nodules. Many cases have come 
to light since this, which modify some of these statements. In 
the case of Vincentiis,f a girl of twenty, it began when five 
years old without apparent cause, affected the eyelids, 
shoulders, and hands, in plaques and nodules. In a case of 
Hutchinson's $ the disease began on the middle of the eyelids, 
and soon after on the ear lobes as large as a finger-tip. In a 
case of Barlow's, § congenital, but with subsequent develop- 
ment, in a boy nearly seven years old, it was also on the eyelids 
in patches, and there was yellow pigmentation on the lobes of 
the ears and elsewhere. In a still more remarkable unpublished 
male case of his, which I saw, the disease began when a year 
old, without known cause, in the right upper eyelid; at six years 
old the lesions were in patches and nodules, surrounded both 
orbits, and were deeply pigmented, of a dull dark brown color 
in the greater part, and dull yellow in the rest; there were 
more typical lesions in other parts of the face and on the back 
of the forearms; the child presented some signs of hereditary 
syphilis, and had an enlarged liver and spleen. Jackson's case || 
was remarkably extensive and very symmetrical, the eyelids, 
especially the right, were much affected, and no part, except 
the hands, feet, and scalp, was quite free; it was said to have 
commenced when three months old. Kobner's caseT began at 
two years old on a vascular pigmented nevus in the right 
axillary region. When Kobner saw him he was aged twenty- 
seven, and the growths, which were numerous and in rows on 
the axillary folds, were from brownish-red to violet, sprinkled 

* Torok collected thirty cases up to 1893. 

f Quoted by Chambard, with critique of histology, in Ann. de Derm, et 
de Sypk., vol. v. (1884), p. 81. 

X Archives, vol. ix. p. 201. 

%Path. Trans., vol. xxxv. (1881), p. 405, with colored plate. 

\\Amer. Jour. Cut. and Gen.-Urin. Dis., vol. viii. (i8qo), p. 241. 

T[ Kobner, Viertelj. f. Derm. u. Sypk.^ vol. xv. (1888), p. 393 (colored 
plate). Abs. in Annates de Derm., etc., vol. i. (1890), p. 359. 



742 



DISEASES OF THE SKIN. 



over with yellow papules. There had been some lesions in the 
left axilla, but they had flattened down to reddish-brown spots. 
In spite of their color the histology showed that they were 
xanthoma. There were also numerous vascular nevi, the size 
of a pin's head, in the lower axillary region. 

Gwynne of Sheffield had a case of a boy, set. nine, in whom 
the disease began when four years old, first on the elbows, 
then over the tendo Achillis, on the web of the fingers, and on 
the ears. There was nothing in himself or in his family history 
to account for it; the lids were not affected, but they were in 
Letzen and Knauss' case,* which also began when four years 
old on the eyelids, after suffering from many widespread ab- 
scesses, and, as in Startin's case, the nodules were abundant on 
the borders of the anal cleft. 

In a case reported by A. Ponsgen.f a boy, set. twelve years, 
the eyelids escaped, the limbs were chiefly affected, and the 
disease, which began when he was ten years old, was associated 
with aortic stenosis, rheumatic nodules, and fatty tumors. 

In a man of twenty-three, recorded by Thibierge, J the 
tumors were enormous, they began at eight years of age, and 
his brother also had the disease. I have met with a very 
similar, but not quite so highly developed, a case in a youth, 
on whom it had commenced, at the age of fourteen, simul- 
taneously on the elbows and knees. A brother was slightly 
affected. 

In a case of my own, a healthy boy of two years, there was 
a single oval yellow nodule, five millimeters long, on the left 
lower eyelid, which had been growing six months; it was ex- 
cised, and proved to be of the usual structure. 

In another case, a boy of six, brought to the Shadwell Hos- 
pital for articular rheumatism, there was a smooth flat patch 
on the middle of the right eyelid, of a buffy-white color, and 
made up of slightly raised, soft, millet-seed-sized granules. 

I have also met with a yellowish-white patch, exactly like 
xanthoma, imbedded in the tongue near the tip, to the right 
of the raphe, in a female infant, set. three months; it was first 

* Virchow's Arch., vol. cxvi. (1889), Heft i., with plate. 
\ Virchow's Arch., February, 1883, with resume of whole subject of 
xanthoma, and extensive collection of cases. 

% International Atlas, Plate XLL, with histology hy Darier. 



XANTHOMA. 743 

noticed when the child was two weeks old, and was most likely 
congenital. 

Probably, therefore, slight developments of xanthoma are 
not so rare in children as is generally supposed, but give no 
trouble and are overlooked. It is noteworthy that in all these 
three cases the lesions were unilateral. 

Etiology. — The etiological relations are the most interesting 
features in the disease, but it is essential to consider eyelid 
apart from multiple cases, and those occurring before puberty 
from those after that period. Taking X. palpebrarum first, it 
it certainly more common in females than males, but owing 
to these and multiple cases being mixed up in most statistics, 
it is impossible to state in what proportion; Hutchinson's 36 
cases make it 3 to 2. Most cases begin over forty years ; the 
extremes, excluding children, are 20 to 84 (Hutchinson). The 
disease shows remarkable family prevalence, and may be 
hereditary. In Church's series 1 male out of 5, and out of 12 
females who had reached the age of forty, 3 of the first genera- 
tion and 2 of the second were attacked. Hilton Fagge men- 
tions an instance in which mother and daughter were affected, 
and the disease had existed for four generations in their family; 
and Torok, in which it affected three generations. It may also 
skip a generation; thus Hutchinson records an instance of two 
brothers and their paternal grandmother having it. 

Of other conditions, dark-complexioned people, and those 
with a tendency to deep coloration about the orbit, are cer- 
tainly more liable to it, but migraine is the most important 
factor; half of Hutchinson's cases suffered from it. Gout and 
perhaps ovarian disturbances are answerable for a certain num- 
ber; and hepatic derangements, especially such as lead to 
jaundice, are frequent, one-sixth of Hutchinson's cases having 
suffered from jaundice; at the same time it is much less fre- 
quent than in X. multiplex. In one case I met with there was 
diabetes insipidus with some gouty tendencv. 

In X. multiplex, in those above puberty, four-fifths of them 
are associated with chronic jaundice, which has been due in 
different instances to stricture of the duct, gallstone, hydatids, 
cancer, red atrophy, and hypertrophic cirrhosis. It would 
seem, therefore, that jaundice is the chief cause, but in what 
way is not apparent, possibly a toxin is the real factor. Accord- 



744 DISEASES OF THE SKIN 

ing to Besnier * and Gailleton, there is a xanthochromia of the 
skin, not due to jaundice in some cases. It is more marked on 
the face and trunk than on the limbs, but the conjunctivae and 
buccal mucous membranes are uncolored, and there is no bile 
in the urine and feces. 

In cases without jaundice, including one of my own, there 
has been in some a history of migraine, and the sister of my 
case had eyelid xanthoma on the right side and migraine; 
another had syphilis; and there was no obvious cause in the 
other three. The cases associated with diabetes mellitus pre- 
sent many peculiarities, and are described separately. 

Xanthoma below puberty is still rarer than after it, less than 
forty cases being recorded. It is not associated with jaundice 
as a rule, but shows a family prevalence; eight out of thirty 
cases Torok found in four families. It is occasionally con- 
genital and hereditary, and in several instances a rheumatic 
and gouty inheritance has been present. 

Pathology. — The process in X. tuberosum is essentially that 
of a connective tissue neoplasm in the corium, whether inflam- 
matory or not is disputed, in the meshes of which lie large 
epithelioid, fattily degenerated or infiltrated cells, or, as some 
say, masses probably derived from the connective tissue ele- 
ments, while yellowish-brown pigment is deposited in the rete. 
For my part I consider inflammation as the primary feature, 
and the xanthoma cells and the connective tissue growth sec- 
ondary, and the whole process of toxemic origin. Kobner 
thinks the lesions are derived from embryonic remnants, and 
the view that they are closely allied to non-vascular nevi finds 
advocates in Hallopeau and others, and explains well the 
juvenile cases which are sometimes associated with other forms 
of nevus. 

Torok concludes that the xanthoma plaque is composed of 
adipose cells interrupted in their progress to complete evolu- 
tion, and that it is not a tumor, but an excess of growth. 

Unna says that the fat in X. palpebrarum is a sort of fatty 
infiltration of the orbicularis muscle, the fat being in the lymph 

* Besnier, Hallopeau, and Kaposi regard the jaundice and visceral 
troubles as secondary, and due to the xanthoma process in the viscera. 
The clinical order of development of most cases does not support this 
view. 



XANTHOMA. 745 

spaces, and the giant cells being sections of dilated lymphatics. 
Pollitzer follows Unna, and says that the eyelid lesion is a dif- 
ferent process altogether to the nodular form; it is the product 
of the degeneration of embryonically displaced muscle fibers. 
Previously the differences have been regarded as only due to 
the predominance of connective tissue growth in the nodular 
form; and against Pollitzer's view is the clinical fact that both 
in adults and children it is not unusual for the disease to begin 
in the eyelids and then spread all over the body. 

Darier, who examined the large tumors of Thibierge's case, 
came to the conclusion that it was a perivascular, and conse- 
quently convoluted, neoplasm. The xanthomatous matter was 
contained in the cells (differing from Unna's view) which are 
derived from the connective tissue cells. The giant cells were 
very numerous except in the subepithelial zone. The tumors 
showed all the characteristics of xanthoma, and it is unusual 
to find them all in one tumor. 

Anatomy. — The anatomy has been investigated by myself, and by 
numerous observers, of whom Chambard,* Balzer,f Touton, :{: Torok, 
Unna, Pollitzer, § etc., have made the most complete examinations. 
According to Chambard there are two processes going on, an increase of 
connective tissue and a fatty degeneration or deposition, the results of a 
chronic inflammatory process; in the soft plaques the fatty change, and 
in the nodules the connective tissue growth predominates, being greatest 
in the larger and firmer ones. 

Touton disputes these simultaneously progressive and retrogressive 
processes ; he regards xanthoma as non-inflammatory, and as a veritable 
new growth, composed of elements which are not normally present in the 
corium. The " xanthoma cells," which he says are infiltrated with fat 
from the first, have a distinct membrane, finely granular or fibrillated 
contents, and large round or oval nuclei. He thinks there are mixed 
tumors, such as fibro-sarco-myxo- and cyst-adeno-xanthomas, and that 

* Chambard, " Des formes anatomiques du xanthelasma cutane," 
Archives de Physiologie, 1879, P- ^4 X > with plates. 

f Balzer, " Recherches surles caracteres anatomiques du xanthelasma," 
Archives de Physiologie, 31-ne serie, 1884, p. 65. 

% Touton. " Ueber das Xanthom insbesondere dessen Histologic und 
Histogenesis," Viertelj.f. Derm. u. Syfih., vol. xii. (1885), Heft i. p. 3, 
with plates and full references to previous observations. 

§ Pollitzer, "The Nature of the Xanthomata," New York Med. Jour. 
July 15, 1899. L. Torok, " De la nature des Xanthomes," Annates de 
Derm, et de Syph., vol. iv. (1893), November and December, and p. 50, 
vol. v. Unna's " Histopathology," p. 945. 



746 



DISEASES OF THE SKIN, 



there is cystic transformation of the confluent destroyed xanthoma cells. 
L. Dore thinks that there are also myelo-xanthomas, and that the cells 
of each have a common pathogenetic origin. No one accepts Balzer's 
parasitic infective theory, which does not at all accord with the general 
facts ; moreover, the specimens were taken twenty-four hours after death. 
I examined a large plaque from the eyelid of a woman who was a martyr 
to migraine, and had X. multiplex without jaundice then, though it de- 
veloped subsequently. I found large epithelioid, multi-nucleated, oval, 
roundish, or polygonal, finely granular cells in a fine meshwork of con- 
nective tissue. In very fine sections each cell can be seen to lie in a 




Fig. 37. — Large xanthoma plaque from eyelid. 2-fn. oc, £-in. obj. 
a, rete Malpighii, many of the cells of which are undergoing vacuolation 
as at e ; b, cylindrical masses of xanthoma cells formed round a 
vessel ; c, hair follicle ; d, large multi-nucleated granular xanthoma 
cell. 



mesh of connective tissue, the cells being either in irregular masses, or 
in many instances arranged in whorls or nests round a center, this arrange- 
ment being due to their formation round a blood-vessel. The individual 
cells vary much in size, have a defined outline, are finely granular, with 
from one to half a dozen or more nuclei (see Fig. 37). 

The process is chiefly in the middle and lower layers of the corium, 
through which yellowish-brown pigment is scattered, both free and in 
cells, the papillary layer being almost normal. There is also a certain 
amount of deposition of yellow pigment granules in the rete cells, a large 
proportion of which show vacuolation in a varying degree. This struc- 



XANTHOMA. 



747 



ture agrees with that described by Touton. The origin cf the cells in 
X. palpebrarum is traced by Pollitzer to degenerated muscle cells, while 
he admits that X. tuberosum and the lesions of X. diabeticorum are both 
connective tissue neoplasms, in which the relative proportion of fibrous 
tissue and connective tissue cells varies in different cases. In both, the 
cells undergo fatty degeneration, resulting in the destruction of the cells, 
and ultimately in the more or less complete disappearance of the nodule. 
In the nodules the process is more superficial; the bulk of the lesion, 
being situated in the papillary layer, pushes up the epidermis above the 
level of the surrounding surface. The connective tissue is increased, 
distributed in foci, and in greatest abundance round the hair follicles and 
sebaceous g.lands; the fatty masses are less conspicuous, but yellow oil 




Fig. 38. — A small nodule of xanthoma tuberosum from the elbow, show- 
ing that the lesion is situated almost entirely in the papillary layer, 
pushing up the rete into a nodule. Almost the whole morbid area 
is made up of epithelioid cells. X i-in. Ross, 2-in oc. 

globules infiltrate the meshes between the fibrous tissue. Chambard also 
found peri- and endarteritic and perineuritic thickening, but probably 
this is only present in the nodules in which the connective tissue increase 
is considerable (Darier). 



Xanthoma Elasticum (Balzer),* or Pseudo - xanthoma Elasticunio 
Balzer described a form in which the elastic tissue was in numerous large 
coils, chiefly round the follicles, and formed the greater part of the 
tumor. The fibers were swollen, degenerated, and in parts broken into 
and segmented. In Balzer's case the lesions began in early infancy, 
and wsre flat and pale yellow, sometimes papular, and were widely 

* Balzer, loc. cit. 



748 DISEASES OF THE SKIN. 

distributed in the folds of flexion. Besnier and Doyen* quote another 
case by Chauffard with very similar features, Besnier comparing it 
with X. diabeticorum. The eyelids were free in both cases. Darier'sf 
microscopic examination was made on material from this case. 

He confirms Balzer's observations with regard to the elastic fibers, but 
considers it a different disease to xanthoma, as xanthoma cells and flatty 
granules were absent. Bodin X has published a third case, a man of fifty, 
in whom the skin affection had existed for thirty years without inconven- 
ience. There was a palm-sized median patch below the umbilicus, and 
others strictly symmetrical in the mid-clavicular region, the anterior fold 
of the axilla, the inner central part of the arm, the upper and flexor 
aspect of the forearm, and the upper and inner part of the thigh. The 
eyelids and other usual positions of xanthoma were free and the mouth 
was unaffected. In the center of the patch the individual lesions were 
confluent, but were discrete in normal skin at the periphery, where they 
varied, and in size from a pin's head to a pea. They looked like little 
yellow masses of butter beneath the normal epidermis. In this patient, 
like the other, there was advanced lung tuberculosis, and neither hepatic 
nor diabetic symptoms. Bodin confirmed Darier's observations and con- 
sidered the process due to a degeneration of elastic tissue; the giant cells, 
he observed, were quite different from true xanthoma cells, consisting of 
masses of nuclei imbedded in very little protoplasm. The resemblance, 
therefore, is only a clinical one. Clinically, the quite different distri- 
bution, the absence of hepatic and renal disease, and the flatness of 
the lesions are the chief points of distinction from true xanthoma. 
Payne has described a generalized xanthoma with abundant elastic tissue, 
but in his case regarded the excess as only relative to the atrophied con- 
nective tissue. 

Diagnosis. — The presence on the eyelids of chamois-leather- 
colored patches, imbedded in the corium, without imparting a 
notable change in texture to the touch, is very distinctive. 
Milium § may present a slight resemblance, but when large 
enough to simulate xanthoma, the little tumors are hard and 
tense, do not coalesce completely, are whitish in color, often 
with a black center like a comedo, and more superficial, being 
imbedded in the epidermis, from which they can easily be 
shelled out by an incision over them; moreover, if pricked, 
some of their contents can be squeezed out, and this will settle 

* Besiner-Doyen's Kaposi, vol. ii. p. 336. 

fDarier, Third Internat. Cong. Rep., 1896, p. 289; Unna's " Histopa- 
thology," p. 953- 

\ Bodin, Annates de Derm, et de Syph., vol. i. (1900), p. 1073. Good 
abs. in Brit. Jour. Derm., vol. xiii. (1901), p. 231. 

§ Author's Atlas, Plate LXVIII. Fig. 2, shows grouped milium at inner 
canthi. 



XANTHOMA. 



749 



the matter. Solitary lesions in children are to be distinguished 
by their color and softness from non-pigmented or white moles, 
and the latter are always congenital, which xanthoma very 
rarely is. 

X. multiplex in the adult nearly always has jaundice to point 
to the right conclusion. The presence of the lesions in the 
corium must be borne in mind, as a case is published in the 
British Medical Journal, by a good observer as a rule, as one 
of X. multiplex, where yellow spots were in the epidermis only, 
and came off after soaking in olive oil. 

In two instances * to my knowledge cases of urticaria pig- 
mentosa of infancy and childhood have been reported as X. 
multiplex. The early onset of the lesions without being con- 
genital is very unlikely; then the lesions are firm in the urticaria 
and soft in xanthoma. Itching is nearly always a prominent 
symptom in urticaria pigmentosa, and close observation would 
detect the occasional presence of ordinary wheals, while facti- 
tious urticaria can generally be demonstrated. Pollitzer f 
records a case from Sangster's clinic in which multiple dermoid 
cysts, to the number of about 150, almost white or of a lemon- 
yellow color, were indistinguishable from X. multiplex until 
microscopic examination was made, and refers to other cases of 
similar character and consequent error. Sangster's case was 
a woman, set. twenty-four, in whom the disease began when 
sixteen years old. The tumors were situated symmetrically 
behind the ears, on the neck, and chest. Two of her brothers 
also had it. All the members of the Dermatological Society 
considered it a xanthoma. 

Prognosis. — The involution of the lesions observed in the 
cases of Fagge, Frank Smith, Legge, Kaposi, and Pollitzer 
does not materially alter the prognosis, which is that, after 
progressing up to a variable extent, the lesions become sta- 
tionary, and remain so for the rest of life. Pollitzer's more 
favorable prognosis is not supported by clinical facts, though 

* Tchistiakoff 's case, abs. in Brit. Jour. Derm., vol. iii. (1891), p. 65, is 
evidently of this kind, and Dr. Barr's case in Lancet, May 12, 18S8. He 
was kind enough to show me the case at the Leeds meeting of the British 
Medical Association, and I recognized it as urticaria pigmentosa without 
doubt. Urticaria factitia also was present. 

\ Brit. Jour. Derm., vol. iii. (1891), p. 398. 



750 DISEASES OF THE SKIN. 

doubtless the nodular is more likely to involute than the plane 
form. 

Treatment. — Excision is the only means of cure, since the 
disease lies in the corium. Dissection through the whole thick- 
ness of the skin is required, but great care is necessary not to 
go too deep on the eyelids, or ectropion is produced. Especial 
care is required near the inner canthus of the lower lid, as very 
slight contraction will produce epiphora. The result is very 
satisfactory, as a linear cicatrix is nearly always possible, and 
this is imperceptible in the folds of the eyelid. Success has, 
however, been obtained by other means; thus, by rubbing in 
soft soap and making the patient wear india-rubber gloves, 
Kaposi removed from the hands some tubercles which he re- 
garded as xanthomatous. Morrow applied salicylic plasters 
twenty-five per cent, to nodules on the soles and knees, and 
when the plaster was removed the epidermis and a number of 
xanthoma nodules came with it, while the others were so much 
softened that they could be curetted out. Fox of New York 
removed patches on the eyelids by electrolysis in five sittings 
of one minute each, and a current of one to three milliam- 
peres; McGuire of Georgetown destroyed the disease in two 
cases by repeated applications of monochlor-acetic acid. 
Painting the palms with collodion containing five per cent, 
perchlorid of mercury gave great relief in Darier's case, and 
Leslie Roberts used salicylic acid 5j, chrysarobin oss, ol. ricini 
3ss, collodion flexile *j with disappearance of palmar lesions, 
but without affecting those on the elbows and buttocks. 



XANTHOMA DIABETICORUM.* 

This is an extremely rare affection, but it is becoming gen- 
erally recognized, and there were over thirty cases on record 
up to 1900. It differs in many respects from the usual type of 

* Literature. — Author's Atlas, Plate LIX. Dr. Hughes' case, p. 160 of 
Syd. Soc. ed. of Addison's works, model 2738, Guy's Museum. Path. 
Trans., vol. xvii. (1S86), p. 414, a case called by Bristowe " Keloid of a 
rare form." Malcolm Morris, Path. Trans., vol. xxxiv. (1883). p, 278, 
with plate of histology, and at p. 284 is the report of the committee on 
the subject. A case in Hillairet's clinic, reported in Gendre's " Paris 
Thesis on Xanthelasma." Chambard also has written a critique on the 



XANTHOMA DIABETICORUM. 751 

xanthoma. The first cases were reported by Addison, Bristowe, 
and Malcolm Morris, to the last of whom belongs the credit 
of recognizing it as a clinical entity. 

Symptoms. — The eruption consists of dull red, discrete or 
confluent papules, quite firm to the touch, from a line to a 
quarter of an inch in diameter, well defined at the margin, and 
roundish or obtusely conical. On the top of many of them, 
but not of all, is a yellow or yellowish-white head, which looks 
like a pustule, but is really solid, and some of the papules are 
dotted or streaked with red from dilated vessels; a red areola 
is sometimes seen. Itching, pricking, or tenderness is gen- 
erally felt in the lesions, and in one case shooting pains pre- 
ceded the eruption. The most common positions are the but- 
tocks,* elbows, and knees, where they are generally confluent f 
and may form tumors, though the papular origin is generally 
still discernible. They have also been seen on the trunk, on 
the extensor surfaces generally, on the mucous membrane of 
the mouth, on the face, scalp, and bend of the ankles, but are 
rare on the other flexures, and on the eyelids in Besnier's case. 
In most cases the lesions are not very numerous, but in some, 
such as Robinson's, Hutchinson's, and Morris' second case, 
the eruption is very extensive, the lesions being in such cases 
very distinctive, with the yellow apex on a red base of larger 
diameter. The eruption comes out rather suddenly at first, 
upon the extensor aspect of the limbs, especially the forearms, 
and then more gradually in other parts; after remaining sta- 
tionary for some time — months, or even years — the papules 
begin to disappear, rather quickly when they once begin to go, 
leaving no trace behind them, or, while some disappear, others 
come out; or again, they may disappear entirely for a time and 
then break out once more. 

subject in Ami. de Derm, et de Syfih., vol. v. (1884), p. 348. Besnier, 
Ann. de Derm, et de Syftk., i88g, No. 5. Brit. Jour. Derm., August, 
1892, — cases by Morris and myself, with histology. Torok, loc. cit., Part 
II., who gives references to fifteen cases up to 1892. There are colored 
illustrations to Jamieson's case in Brit. Jour. Derm., vol. vi. (1894), p. 
289. Norman Walker's case, loc. cit., vol. ix. (1897), p. 461, with a table of 
thirty cases. 

* In Jamieson's case the buttocks and lower limbs were free. 

f In Pollitzer's case there were large masses on the elbows. Although 
there was abundant glycosuria in a boy of seventeen, it is probable from 
the description that it was an ordinary X. multiplex. 



752 DISEASES OF THE SKIN. 

In a case of Sequeira's the lesions were in chains tending to 
form circles, " like a string of yellow coral beads." 

Etiology. — Only about one in ten is a female. The ages have 
been from twenty-one (Norman Walker *) to fifty-seven (John- 
stone)^ there has been diabetes mellitus in most of the cases, 
in Bristowe's probably after the eruption, in Hallopeau's and 
Cavafy's before it — at least the patient had been told he had it 
and Bright's disease, but there was no sugar or albumin when 
he came under observation. Hutchinson's case, however, a 
stout man, never had diabetes or jaundice; his disease came 
on after "a bilious attack," to which he was subject; it was, 
however, of the same type as the other cases, and got quite 
well. Besnier also mentioned a case where there was no 
diabetes, but the patient was obese and his father was diabetic. 
Vidal's, Payne's, and Sequeira's cases also had no sugar, so 
it is not an essential feature. Colombini's case had no sugar, 
but had pentose and albumin; several of the other cases have 
had albumin with sugar. 

It is noteworthy that, while a few have had typical diabetes, 
most cases have been stout and well-conditioned, and their 
aspect by no means suggested diabetes, so that the eruption 
becomes of some diagnostic value. In my own case it was 
quite unsuspected until the eruption put me on the track. On 
the other hand, a woman, get. thirty-two, a patient of Abra- 
ham's, presented typical X. diabeticorum, and had the classic 
symptoms of diabetes. 

In Darier's case, in the St. Louis Atlas, there was hyper- 
trophic cirrhosis, obesity, and glycosuria, and the whole style 
of the case was that of ordinary X. multiplex. 

Pathology. — The diseased process appears to be anatomically 
of the same nature as ordinary nodular xanthoma, but with 
more inflammatory phenomena and less connective tissue 
growth. Since Bristowe and Morris first made anatomical in- 
vestigations the histology has been more thoroughly gone into 
by Robinson4 Clarke § on Morris' second case, myself, Nor- 

* Norman Walker's and two of Hillairet's. One of these, by Gendre, 
Torok regards as an ordinary X. multiplex. 

f Pollitzer's doubtful case was seventeen years old. 

% Brit. Jour. Derm., vol. iii. (1891), p. 106; and International Atlas, 
Plate XIII. 

§Path. Trans., vol. for 1892, Plate XLIII. 



XANTHOMA DIABETICORUM. 



753 



man Walker, and Unna. The last two are quite in agreement 
and, as before stated, while Unna regards ordinary X. tuber- 
osum and X. diabeticorum as variations in the same process, 
he considers them both as essentially different from X. planum. 
Krzysztalowicz * has also examined a case. In X. diabeticorum 
the whole of the process is in the corium, either superficial or 
in the center. Large cells f with several nuclei are found in 
this as in the other form, and they seem to be in abundance in 
proportion to the size of the lesions. There are, however, few 




Fig. 39. — A general view of a small nodule of xanthoma diabeticorum, 
showing that the diseased area extends from the rete Malpighii 
through the whole depth of the corium, and that it consists of around- 
cell infiltration with small groups of epithelioid cells scattered through- 
out it. Compare with Fig. 38. X i-in. Ross, 2-in. oc. 

in a very early papule, and they are much less developed than 
ordinary xanthoma cells. In this form also there is no actual 
connective tissue growth, but Robinson found proliferation of 
connective cells in large papules. Round-cell infiltration and 
dilated vessels are here much more marked than in ordinary 
xanthoma. There is also a greater tendency of the lesion to 
be situated at the hair follicles. As might be anticipated from 
the clinical features, the predominance of active inflammatory 
changes is the most important and striking difference between 
the two forms. 



* In Unna's laboratory, Monatsh. f. Derm., vol. xxix. (1899), p. 201, 
illustrated, and numerous references. 

f Norman Walker, Brit. Jour. Derjji., vol. ix. (1897), p. 461. Unna 
found no multi-nuclear cells. " Histopathology," p. 951. 
48 



754 



DISEASES OF THE SKIN. 



With regard to its pathogeny, in diabetes, as in jaundice, dis- 
order of the hepatic functions exists, but the clinical facts show 
that derangement short of that necessary to produce either 
diabetes or jaundice may yet produce xanthoma. 

Diagnosis. — The disease differs from ordinary xanthoma in 
the following particulars: The sudden evolution and involution 
of the eruption, the latter always ocurring sooner or later,, 
while, in xanthoma, involution is very exceptional and gradual.. 
The lesions are firm and solid in X. diabeticorum, but in xan- 
thoma all except the largest tumors are soft at the commence- 
ment; in X. diabeticorum they are inflammatory, and, as Ad- 
dison described them, of "a lichenous character"; the yellow 




Fig. 40. — A small portion of Fig. 39, more highly magnified to show the 
epithelioid cells, some of them multi-nucleated. X i-in. Ross, 2-in. oc. 



top is not present at first, nor in all papules. In xanthoma 
visible signs of inflammation are quite absent, and the yellow 
tint is always present. There are never any patches or striae,, 
but always nodules or infiltrations; this is exceptional in X. 
multiplex. In the latter, also, it is very rare in the adult not 
to find jaundice, and for the lesions to be absent from the eye- 
lids; moreover, the ordinary form has never been observed 
with diabetes mellitus except in the cases of Besnier's, Darier's, 
and perhaps of Pollitzer's, though it has with insipidus. Sub- 
jective symptoms are the rule in X. diabeticorum, the excep- 
tion in X. multiplex. Finally, the lesions, in many instances, 
are in the neighborhood of the hair follicles, which is not the 
case in the ordinary form, and the microscopic appearances are 



COLLOID DEGENERATION OF THE SKIN. 755 

also different. Probably the comparative acuteness of the 
process accounts for all these dissimilarities. 

Prognosis. — All the cases get well, the majority in a few 
months; one lasted over five years. 

Treatment. — The measures requisite for diabetes exercise a 
favorable influence on the eruption. Several have appeared to 
benefit by the administration of arsenic, but the special diet, 
etc., for the diabetes may have been the real cause of the im- 
provement; it is, however, a good tonic, so may be tried. If any 
local treatment is required to allay the irritation, liq. carbonis 
detergens TTLx to §j of calamin lotion would probably fulfill all 
indications; or olive oil might be rubbed in, with or without a 
few drops of oil of cade. 

COLLOID DEGENERATION OF THE SKIN.* 

This very rare affection was first described by Wagner as 
colloid-milium. Cases have since been reported by Besnier, 
Liveing, Feulard, and others. 

Symptoms. — It occurs chiefly upon the upper two-thirds of 
the face, especially upon the cheeks and orbits, the bridge of 
the nose and forehead, but in a case of Liveing's the neck and 
upper arms were also involved. The lesions form slowly in 
groups, but are not confluent, and consist of pin's-head to 
millet-seed or split-pea-sized, glistening, translucent, lemon- 
yellow, flattish elevations imbedded in the skin, looking as if 
they contained fluid, but when pricked a small jelly-like mass 
and a drop of blood are all that can be squeezed out. Some 
have dilated vessels round them, and soon become depressed 
in the center till the whole is gone, leaving a depression; or 

* Literature. — Wagner, "Das Colloid-Milium der Haut," Archiv der 
Heik., bd. vii. (1866), p. 463. Besnier, Ann. de Derm, et de Syph., vol. 
x., Nos. 5 and 6 (1879); ibid., vol. vi. (1885), p. 342, with histology by 
Balzer. Models 614 and 1019 in St. Louis Museum. Liveing, three cases 
in Brit. Med. Jour., March 27, 1886. These were not examined micro- 
scopically. Unna's " Histopathology," p. 988, and on " Special Staining," 
p. 982. " Colloid Pseudo-Milium," C. Pellizzari, Giorn. Ital. d. Mai. 
Ven. e d. Pelle, vol. vi. (1898), p. 692. Abs. Brit. Jour. Derm., vol. xi. 
(1899), p. 371. Petrini de Galatz reported a case under Colloid at the 
Congress of Dermatologists at Graz, Archiv f. Derm., vol. xxxiv. (1896), 
but it was an epithelial disease of a different character. 



756 DISEASES OF THE SKIN. 

they may inflame and scab over and dry up, leaving a mark, 
but not a defined scar (Liveing). The disease affects both men 
and women from the age of sixteen and upwards, without any 
departure from health to account for it. Wagner thought that 
the change began in the sebaceous glands, but Balzer, who ex- 
amined both Besnier's and Feulard's cases, considers that the 
degeneration commences as an infiltration in and round the 
fibers and cells of the upper part of the corium, especially in 
the neighborhood of the sebaceous glands and their sacs. All 
epithelial structures escape, except the endothelium of the ves- 
sels, which may be attacked with the rest of the walls. There 
were no cysts or cavities lined with epithelium and filled with 
colloid substance, and no epithelial bands. Whether the affec- 
tion is due to vascular alterations in the first place he could not 
determine, but thought it probable. The absence of cavities, 
etc., is emphasized, as L. Philippson * has endeavored to estab- 
lish the identity of colloid of the skin with the hydradenoma of 
Darier and Jacquet, founding his view on his microscopical ob- 
servations on two cases from Unna's clinic. Besnier, however, 
who is familiar with both affections, disputes their clinical 
identity, pointing out that in colloid the lesions have uniform 
characters, are limited to the face (this was not so in a case of 
Liveing's), are not congenital, but of comparatively recent de- 
velopment, and are not associated with other lesions. Balzer, 
who also examined the Darier-Jacquet case before they did, dis- 
putes the histological identity of colloid with hydradenoma. 
At the International Congress of Dermatologists of ' 1892, 
Perrin of Marseilles reported another case with histological ex- 
amination. The patient, a woman of fifty-four, in bad circum- 
stances, and much exposed to the weather, had an eruption like 
the cases of Besnier and Feulard on the upper part of the face 
and the ocular conjunctivae, and, in addition, had similar lesions 
on the backs of the hands. The histological examination by 
Reboul showed the colloid change in the walls of the vessels 
and in the connective tissue, which was much increased, thus 
confirming the observations of Besnier and Balzer, and dis- 
proving that of Philippson. For the further discussion of the 

* Brit. Jour. Der?n., vol. iii. (1891), p. 35. He critically reviews all 
previous cases of colloid, with their references. Besnier's answer to this 
paper is a long and important note in Kaposi-Besnier, vol. ii. p. 370. 



COLLOID DEGENERATION OF THE SKIN. 757 

subject, the reader is referred to Lymphangioma Tuberosum 
Multiplex. 

A case reported by G. H. Fox as probably colloid was pro- 
nounced by Elliot, after microscopical examination, to be of de- 
cided tubercular character. The clinical features also differed 
from other cases of colloid. Pellizzari's case was a man, set. 
forty-five, much exposed to the weather, and also, like Perrin's 
case, the lesions were on the back of the hands, the cheeks, and 
nose. They were yellowish papules from a large pin's-head to 
a pea in size, slightly transparent, but on section no fluid 
exuded, but a small round body of gelatinous appearance es- 
caped. There was no sign of inflammation. Histologically 
there were cavities in the derma containing hyaline masses, the 
elastic fibers had gone, and the external and middle coats of the 
vessels showed hyaline change. The epidermis was normal. 
La Meusa's * case was also a man exposed to the weather, and 
the histology showed that the process was due to a degenerative 
change in the elastic fibers. 

Charles J. White f has recorded a seventh case, an Irishman, 
set. fifty-two, also exposed to the weather. The lesions began 
on the back of the hands, and when seen were also on the face, 
radiating from the outer canthus, and on the cheeks and ears, 
where they were very abundant. Each lesion was a smooth 
flat papule one-eighth to one-quarter of an inch in size, pro- 
jecting one-eighth of an inch, of irregular outline, very trans- 
lucent, yellowish-brown in color, and soft, elastic, and almost 
gelatinous to the touch. On section the papillae were quite 
gone, nearly the whole of the corium having been replaced by 
the colloid material, leaving only a narrow zone of elacin and 
a few connective tissue fibers. The true colloid £ was com- 
posed of a groundwork of fine or coarse granules, staining uni- 
formly with picric acid and other stains; perfect connective 
tissue nuclei were scattered through the homogeneous mass, 

*Abs. Brit. Jour. Derm., vol. xiii. (1901), p. 316. 

\ Amer. Jour. Cut. and Gen.-Ur. Dis., vol. xx. (1902), p. 49. He has 
missed Pellizzari's and La Meusa's cases and calls his the fifth. 

% According to Unna, collagen (normal connective tissue) breaks up 
and combines with elastin (normal elastic tissue) to form collastin. A 
later step is the combination of collagen with elacin, and produces col- 
lacin, and this degenerates into colloid. The elacin does not undergo 
further change. 



758 DISEASES OF THE SKIN. 

and there were many leukocytes near the capillary boun- 
daries. 

Diagnosis. — The disease may be distinguished from xan- 
thoma, which it most resembles, by the glistening and trans- 
lucent appearance of the granules, and while on the one hand 
it is limited to the face, ears, and hands, on the other it is not 
limited to the eyelids. To distinguish colloid from such cases 
as Philippson's microscopic examination would be required. 
The fact of a patient having been much exposed to the weather 
would be suggestive. 

Treatment. — No internal or external application has any ef- 
fect. One of Liveing's cases got well spontaneously, but very 
slowly. Feulard treated his case with good result by erasion 
of the masses with a sharp spoon. I should try electrolysis. 

Pseudo-Colloid of Lips. — Fordyce * has called attention to this 
curious condition of the lips, which in slight degrees is not very 
rare. It consists of yellowish, semi-translucent miliary masses 
the size of an average pin's head, level with or slightly raised 
above the surface, closely aggregated into a broad or narrow 
line on the red of the lips, while farther in the oral cavity they 
may be in small groups or even single. They are not percepti- 
ble to the touch, give rise to no inconvenience, are generally 
discovered by accident, and require no treatment. In one of 
Fordyce's cases an epithelioma of the lower lip was also pres- 
ent, but no relationship between the two conditions was estab- 
lished. 

Microscopically. — Fordyce found the entire epithelial layer 
considerably thickened, and all the cells except those of the 
lowest layer had undergone a degenerative change of the proto- 
plasm, leaving the nucleus unaffected. The protoplasm was 
broken up into irregular glistening granules, which he did not 
succeed in staining, and the change was not determined, and it 
is only from the clinical aspect that I provisionally suggest this 
name. 

* " A Peculiar Affection of the Mucous Membrane of the Lips and Oral 
Cavity," Amer. Jour. Cut. and Gen.-Ur. Dis., vol. xiv. (1896), p. 413, 
(Colored and microscopic plates.) 



TUBERCULOSIS OF THE SKIN. 759 

TUBERCULOSIS OF THE SKIN.* 

A great variety of skin lesions appear to be due either di- 
rectly or indirectly to tubercle. 

In only a few has the presence of tubercle bacilli been proved 
in the lesion itself, viz., in lupus vulgaris, lupus verrucosus, 
scrofulodermia, and miliary tuberculosis, and even with regard 
to scrofulodermia there is some evidence that throws doubt 
upon its being due solely to tubercle. This is important, as 
there is a tendency to drop the term scrofula as being only 
tuberculosis under another name; it is, however, convenient to 
preserve the old nomenclature, as tuberculosis of the skin has 
too wide a meaning to indicate by itself the character of the 
lesion in question. 

Broadly speaking, the lesions produced by the direct presence 
of tubercle bacilli, with which alone this section treats in detail, 
are characterized by a granulomatous structure with giant cells 
and tubercle bacilli, which are generally in small numbers, as 
the bacilli multiply with difficulty in the skin. 

Clinically, except the miliary form, they are of slow develop- 
ment, are single or in moderate numbers, and symmetrical in 
distribution, and ulcerate either spontaneously or with slight 
provocation, and are then very difficult to heal. When bacilli 
cannot be found directly, their presence may be inferred when 
inoculation of the suspected tissue into guinea-pigs and rabbits 
produces general tuberculosis. 

Miliary tuberculosis of the skin appears to be the direct out- 

* Literature. — Discussion Third. Internat. Cong. Derm., 1896, p. 385, by 
Kevins Hyde, Hallopeau, etc., li Die Exantheme der Tuberculose," von 
C. Boeck, Archiv f. Derm. ti. Syph., vol. xlii. (1898), pp. 71, 175,363. 
"" Die tuberkulosen Erkrankungen der Haut," von Jadassohn in Ergeb- 
nisse der allgem. Path, und pathologischen Anat. des Menschen u. der. 
Thiere von Lubarsch Ostertag. "The Cutaneous Paratuberculoses," by 
J. C. Johnston. Philadel. Monthly Med. jour., February, 1899; good abs. 
in Anier. J our. Cut. and Gen.-Ur. Dis., vol. xvii. (1899), p. 317. Toma- 
soli, Monatsh. f. p. Derm., vol. xxi. (1895), p. 309, sees tubercular in- 
toxication in a large number of heterogeneous diseases, but this only 
shows how common tubercle is in Italy, as his observations are not borne 
out by the experience of others. " Les Tuberculides," Discussion at the 
Internat. Congress at Paris in 1900, p. 95, by Boeck, C. Fox, Darier, etc.; 
and C. Fox's report and table of cases and comments in Brit. Jour. 
Der?n., vol. xiii. (1900), p. 383. 



760 DISEASES OF THE SKIN. 

come of visceral tuberculosis, and visceral tuberculosis appears 
to have resulted from some cases of lupus verrucosus and 
scrofulodermia; but although the two are occasionally asso- 
ciated, it is very doubtful if phthisis has ever arisen from a 
nodular lupus vulgaris. It is said that visceral tuberculosis 
secondary to skin lesions runs a slower and more benign course 
than those which are primary. 

Other lesions of the skin indirectly connected with tubercle 
may be grouped under the French term tuberculides. In some, 
such as lichen scrofulosorum and acne scrofulosorum, the evi- 
dence of this connection is very strong, and they are probably 
due to the tuberculin toxin; indeed, lichen scrofulosorum has 
actually been produced by injection of Koch's tuberculin 
(Schweninger and Buzzi). In others the connection is less 
demonstrable, as in erythema induratum of Bazin, eczema 
scrofulosorum, folliclis of Barthelemy, the pityriasis rubra of 
Hebra, a dyschromia resembling the pigmentary syphilid, lupus 
erythematosus, and sundry anomalous cases which are from 
time to time reported as the result of tubercle. Two or three 
of the above affections may be associated in the same individ- 
ual, and Hallopeau has seen together cutaneous and subcutane- 
ous gummata, lupus vulgaris, lupus verrucosus, lichen scrofulo- 
sorum, and folliculitis. 

The tuberculids are inflammatory in character, and not 
granulomatous in structure, do not contain tubercle bacilli, and 
the lesions are often very numerous, bilateral and even sym- 
metrical in their distribution in many cases, and although the 
disease may as a whole be obstinate, the individual lesions can 
be easily got rid of. In all except lichen scrofulosorum and 
acne scrofulosorum the tubercle toxin theory invoked to ex- 
plain them seems to me highly improbable, since experiments 
on a large scale were carried out when Koch's tuberculin was 
in vogue for the treatment of phthisis, and while many thou- 
sands of injections were given, only lichen scrofulosorum and 
a few papulo-pustules were produced in a few cases; and it 
must be remembered that nearly all the injections were made 
in tubercular subjects. It may well be, however, that the soil 
which we call the tubercular constitution may be favorable for 
the development of other organisms and toxins than those of 
tubercle, and the fact remains that in the victims of these erup- 



TUBERCULOSIS OF THE SKIN. 



761 



tions a very high proportion of them have evidence of tubercle 
in their near relatives, and sometimes in themselves also. The 
evidence is not equally strong for all these diseases, and for 
some of them, especially lupus erythematosus, its connection 
with tuberculosis is regarded by most dermatologists as a very- 
slender one, or is denied altogether, and in this work it is not 
treated as a tuberculosis. 

The following table may be useful, although it is only tenta- 
tive, and for any one disease must be read in conjunction with 
its pathology as set forth in its own section. 

DISEASES DIRECTLY DUE TO THE PRESENCE OF 
TUBERCLE BACILLI IN THE TISSUES. 



Lupus Vulgaris 

Lupus Verrucosus 

Including Tuberculosis verrucosa cutis | 
and Verruca necrogenica. j 

Scrofuloderma 

Including chronic ulceration with or") 
without Lupus Papillomatosus and Tu- I 

ViprAnl-ar r ,-\rmr\V\ anrrific oifVior -nr\r\ 11I ar ri-r \ 



bercular Lymphangitis, either nodular or 



recurrent (Erysipelas perstans of Kaposi), j 
Miliary Tuberculosis Cutis. 



Bacilli sparse. 

Bacilli sparse, but less so 
than in L. Vulgaris. 



Bacilli not always to be 
found; when present fairly 
abundant. 



Acute or chronic, including ulceration. 



Bacilli usually but not 

always sparse in each small 

}■ nodule, but abundant in ag- 

| gregated nodules and result- 

J ing ulcers. 



Erythema Induratum. 

Guinea-pig inoculations successful, but > 

bacilli not found in the tissues. ) 

Some nodular, patchy, ulcerative, suppurative, and otherwise anoma- 
lous cases, from time to time reported, which do not accord with the fore- 
going forms, in which bacilli or a very distinct tubercular structure have 
been found. 

TUBERCULIDES (DARIER) ; PARA-TUBERCULOSES (JOHN- 
STON). 

(Diseases indirectly due to Tubercle Bacilli) 
A. — Probably resulting from their toxin. 
Lichen Scrofulosorum 

And the suppurative folliculitis of the 1 
mons veneris, described by Kaposi in con- I Som ^ observers claim to 
nection with some cases of it. Isolated *> Ve ionT f * aClUl ™ the 
pustules on the trunk are also often I ] e *TV lthasb ^en produced 



present. 



by Tubercle toxin. 



762 DISEASES OF THE SKIN. 

Acne Scrofulosorum 

And other forms of Folliculitis, isolated or in patches, such as are 
described by Hallopeau, etc. {vide end of article on Acne Scrofulosorum). 
Acne Agminata, or Acnitis and Folliclis. 
Morbilliform and Scarlatiniform Erythema occur occasionally in the 

course of acute tuberculosis and after tuberculin injections, but 

resemble those liable to occur from any toxin. 
B. — Probably not due to Tubercle Toxin, but predisposed to by the 
constitution which is favorable to Tuberculosis. 
Eczema Scrofulosorum. 

Pityriasis of Hebra (not the ordinary form). 
Dyschromia, like the pigmentary syphilid? 
Lupus Erythematosus. But Tuberculosis is probably only one of several 

factors, and is probably not constant. 



LUPUS VULGARIS.* 

Deriv. — Lupus, a wolf. 

Synonyms. — Lupus exedens; Fr., Lupus vulgaire; Scrofulide 
tuberculeuse; Herpes esthiomene; Dartre rongeante; Es- 
thiomene; Ger., Fressende Flechte; Lupus. 

Definition. — A neoplastic cellular infiltration caused by the 
tubercle bacillus producing papules, nodules, and patches, 
which either ulcerate or atrophy, leaving scars. 

It is a common disease in this country, forming about two 
per cent, of all cases; as, however, it is an obstinate and very 
chronic affection, dermatological statistics doubtless exag- 
gerate its frequency, as patients come back year after year. 

There are no true varieties of this form of lupus, the numer- 
ous qualifying terms which will presently be explained depend- 
ing upon minor differences, but clinically we see it in a nodular, 
infiltrating, and ulcerative form. 

Symptoms. — A typical case of nodular lupus begins on the 
face, especially the cheek and nose, and nearly always in a 
child. In a cheek case there appear at the commencement one, 

* Literature. — Author's Atlas, PlatesLX. andLXI., show nodularform, 
and some of figures of Plates LXII. and LXIII. show ulcerative varieties. 
St. Louis Atlas, Plate I., and Syd. Soc, Plates III., VI., and VIII., ulcerat- 
ing lupus copied from Hebra's Atlas. Leloir, " La Scrofulo-Tuberculose," 
1892. A valuable monograph, with numerous illustrations of interesting 
cases. 



LUPUS VULGARIS. 763 

or, if several, then grouped pin's-point to pin's-head-sized spots, 
of a dull red color, which, according to the depth of the little 
mass in the cutis, are depressed below, level with, or slightly 
raised above the normal skin, and pale, but do not disappear on 
pressure. These spots gradually develop to small nodules, 
which have a semi-translucent aspect under the stretched epi- 
dermis, and a brownish hue, so that the appearance of the 
nodule has been aptly compared by Hutchinson * to " apple 
jelly." After a variable time, more often years than months, the 
groups of nodules coalesce by individual extension into a dull 
red patch or patches, distinctly raised above the surface, soft 
and elastic to the touch in the center, but firmer at the edge, 
which is more raised and more or less nodular and still trans- 
lucent. By this time there is generally more or less scaliness 
present, but not enough to obscure the ground color of the 
infiltration, which goes on slowly extending at the edge, or 
more commonly by the formation of fresh nodules, which, as 
they enlarge, merge into the major patch. 

There is usually only one focus of disease, but when there 
are several patches, on one or both sides of the face, the dis- 
ease is seldom symmetrical,! except when it begins on the nose, 
and spreads equally on both sides, and then it may assume the 
same shape as L. erythematosus. When the skin of the nose 
is affected, the whole thickness of the soft tissues may be in- 
volved as well; and then, as in all cases when it attacks the 
mucous orifices, ulceration occurs, but, owing to the fungating 
granulations covered with brownish crusts, although swollen, 
the general outline of the nose is long preserved, and it is not 
until these granulations are removed that the amount of de- 

* Hutchinson used the term " Lupus " in a very wide sense. His special 
views are set forth in the Harveian Lectures for 1887, published in Brit. 
Med. Jour., vol. i., 1888; also Post-Graduate Lectures, ibid., vol. i., 1891. 
His smaller Atlas contains many interesting plates of lupus, as he regards 
the diseases he includes under that term, viz., anything which scars and 
spreads especially by what he calls fresh satellites, i. e., foci of the dis- 
ease just beyond the main patch, thus including many non-tubercular 
diseases. 

f In one of my cases the disease was symmetrical on the inner surface 
of both knees, but contact inoculation was the probable explanation; he 
had an asymmetrical patch on one thigh. Morris had a case with lupus 
of the lobes of both ears, probably from inoculation when the ears were 
pierced. 



764 DISEASES OF THE SKIN. 

struction can be fully realized. The disease may ultimately 
destroy all the anterior soft parts, the cartilages and even the 
bones dropping out, but the bones are never directly affected; 
or the infiltrated parts may undergo fatty degeneration and 
atrophy, leaving a thin eroded edge to the widely opened nos- 
trils; but there may be thickened cicatricial contraction when 
the disease is removed by surgical measures. The disease does 
not advance continuously, even in childhood, but has variable 
periods of improvement, quiescence, or activity, in the last 
spreading, or ulcerating, or forming new nodules in old scar 
tissue or at the borders of the infiltration. 

In the adult the quiescent period may last for years, but it 
may break out anew whenever it is subjected to external irri- 
tating, or internal depressing influences. During the improve- 
ment stage more or less of the central part of the infiltration 
undergoes disintegration and absorption, and atrophic scarring 
results, without any external wound at any time. The disease 
as a whole, however, very seldom gets well spontaneously, the 
edge nearly always retaining its vitality even when the interior 
is entirely cicatricial. 

The disease is by no means limited to the face. The next most 
common positions are the limbs, especially below the elbows 
and knees, the buttocks, the trunk, the mucous membrane of 
the nose, eye, mouth, larynx, pharynx, vagina, and uterus; but 
it is nearly always associated with lupus elsewhere, especially 
on the face. While, however, no part is exempt, many posi- 
tions, such as the hairy scalp,* the upper eyelids and middle of 
the forehead, the neck, genitals, palms, and soles are scarcely 
ever attacked, except by extension from the neighboring 
regions, but I have once seen the scrotum primarily and ex- 
clusively attacked with lupus nodules in a boy of six, and 
Matthews Duncan described what he called " lupus of the 

* A curious case of direct inoculation of tubercle bacilli on the scalp 
and the production of lupus is recorded by Wolters. A medical student, 
working with phthisical sputum, scratched frequently a wound on his 
head, from a duel, and typical L. vulgaris developed there. Deutsch. 
Wochensch., September 8, 1892. 

Neisser had a case of a man of forty in whom a patch appeared on the 
scalp, probably inoculated by scratching from an old lupus of the arm, 
Berlin, med. Woche7isch., 1895, p. 53. 

For N. Walker's views on the so-called ulceration of lupus see Anatomy. 



LUPUS VULGARIS. 765 

vulva," but the general opinion is that his cases were examples 
of syphilitic ulceration. It is extremely rare on the scalp,* but 
in a lady under my care lupus began at the climacteric and ex- 
tended rapidly over the whole face and scalp. 

Great variety of aspect is produced by enlargement of old 
patches and formation of new ones in their neighborhood, and 
the presentation of the various stages simultaneously in dif- 
ferent parts of the main area of disease. Thus, in one part, is 
the thin white parchmentlike atrophic cicatrization; in another 
the destruction is deeper, and a seamed scar is the result; here 
one part may be still ulcerating and covered with a dirty green- 
ish crust, there the infiltration is quiescent and covered with 
scales; here new nodules are forming at the periphery, there 
they are just appearing as small brown specks in the scar 
tissue, where at any rate the process seemed to have finished. 

After absorption of a mass of lupus, the epidermis over the 
affected area becomes less dense, wrinkled, and more scaly, or 
even slightly crusted from exudation through a fissure; the 
exfoliated epidermis is constantly renewed, and ultimately the 
center, rarely the whole, sinks down below the border, and 
when the last scales are thrown off the skin is left thin and 
cicatricial, and ultimately white. When lupus ulcerates the 
infiltration gradually softens, and breaks down into a pultace- 
ous pus, which dries up into a greenish dirty-looking crust. 
This, when removed, exposes a freely suppurating ulcer, which 
subsequently granulates freely and exuberantly. 

Great stress used to be laid on the difference between sup- 
purating and non-suppurating lupus — L. exedens or L. non- 
exedens, as it was called. In lupus of the scrofulous more or 
less suppuration is the rule, the ulcerative process being the 
predominant feature, and the brownish-red infiltration incon- 
spicuous; but even the more quiescent nodular lupus will 
ulcerate if irritated, or if at the border of a mucous orifice, such 
as the mouth or nose. 

Variations. — These depend chiefly upon the extent and posi- 
tion of the lesions, the constitution of the patient attacked, the 
amount of infiltration, its rate and mode of progress, its greater 
or less tendency to ulcerate or atrophy, and the complications 
which may arise. The number of foci may be very great; thus, 
* Ulcerating Lupus (L. Exedens). 



7 66 DISEASES OF THE SKIN. 

in one of my cases, a boy of ten, there were forty-seven patches 
from a millet seed to a shilling, scattered over the whole body, 
viz., twelve on the face, one on the neck, seven on the trunk, 
and twenty-seven on the limbs. They were nearly symmetrical 
on the face, and showed very little tendency to spread in nearly 
three years. As usual they came out all together after measles; 
but in another case, which did not begin until he was twenty- 
nine,* patches on the face and limbs came out at intervals 
spread over eight years. When along with multiplicity there 
is a decided tendency to spread, and the disease has lasted many 
years, a very large part,f or nearly the whole body surface, may 
be involved, but such cases are very rare. On the other hand, 
in a few instances, it may be scattered irregularly in small 
patches over one region; thus, in a boy, it followed on herpes 
of the ophthalmic division of the fifth, being limited to the site 
of the vesicles. Kaposi has met with a similar case in a man. 
Such cases, which are most frequent on the face, are well en- 
titled to the term L. disseminatus, which is used for any cases 
with multiple patches, while L. serpiginosus is applied to cases 
where two or more circular patches have coalesced into a 
gyrate form, and enlarge at the margin as new nodules develop 
near it, and coalesce with each other and the parent patch. 
This occurs chiefly on the neck and extremities, and is some- 
times a severe form from its rapid spreading. Such cases may 
be considered as examples of acute lupus. The process is at- 
tended with great hyperemia and heat of the skin, and such 
cases, if they do not break down spontaneously, do so on very 
small provocation, especially if the treatment is of at all an 
irritating character, and they recur very rapidly after scraping. 

L. hypertrophicus is applied to cases where solid lymphatic 
edema is associated with the visible lupus infiltration, such as 
may be often seen in the upper lip, or where there is exuberant 
infiltration, much raised at the margin above the normal skin, 
but generally depressed in the center, as is often seen on the 
buttock, but it may occur elsewhere. Thus Angier records an 
enormous growth of the lobe and lower half of the ear of a 

* Author's Atlas, Plate LXI., Fig. i. 

fSee Plates LXVII., LXVIII., LXXVL, and LXXVII., Hutchinson's 
smaller Atlas. 



LUPUS VULGARIS. 767 

woman. To conceal the deformity she bound it to her head, 
and nodules developed at the points of contact on the scalp. 

The result of central involution with the retention of activity 
at the border is the formation of rings (Lupus annularis),* 
which may enlarge in area while the outer ring may not alter 
in thickness. In strumous subjects the border may ulcerate 
and crust, and this is the most common circinate form, but 
occasionally the same process may be seen in nodular lupus, 
and when there are several rings difficulties in diagnosis may 
arise. 

L. vulgaris fibromatosus. Fibroid lupus is the name ap- 
plied by Unna and his followers to cases in which a good deal 
of the inflammatory process at the base, and round the lupus 
patch, becomes organized into fibrous tissue. Such cases are 
very dense and hard to the touch; they may appear like ordi- 
nary nodular lupus, but resist both the curette and tuberculin, 
which make but little impression on them. It may also be 
met with as part of the so-called hypertrophic lupus. It is 
most common on the buttocks; much less so on the face. In 
a girl of twenty-two the disease began when she was seventeen, 
on the back of the neck, and subsequently the nose, cheeks, 
forehead and orbit, the right ear, hand and arm, occiput and 
palate. On the face they were brownish-red, semi-translucent 
nodules which had coalesced into patches. Most of the lesions 
came out simultaneously. There was slight ulceration about 
some of them. The new tuberculin was thoroughly tried on 
her, but the effect was trifling. She was then scraped, but the 
base of the patches was very resistant to the curette, and could 
not be entirely removed, so it was scarified, and pure carbolic 
acid applied, and great improvement resulted in a month. Sub- 
sequently the Finsen light treatment was thoroughly tried 
without any improvement. 

In adults, very rarely in children, the infiltration is very 
slightly or not at all nodular, but in plaques slightly raised 
above the surface, and more so at the border than the center. 
The color is red, with slightly brownish tint, but is not trans- 
lucent, like ordinary lupus nodules. There may be only one 

* Author's Atlas, Plate LXIL, Fig. 1; G. S. Elliot's case also, Amer. 
Jour, Cut. Dz's., vol. xiv. (1896), p. 476, presenting unusual features. 



7 68 DISEASES OF THE SKIN. 

patch or more, and in some cases, especially if the disease is 
bilateral, it is a little difficult to say whether it is a L. vulgaris 
or a L. erythematosus. Leloir * described a L. vulgaris 
erythematodes, which closely resembles L. erythematosus; 
inoculation of guinea-pigs with some of the tissue produced 
tuberculosis, and tubercle bacilli were found in the tissue. In 
some parts the lesions histologically resembled L. vulgaris, 
while in others they were clinically like L. erythematosus. 
Leloir says that it may take the butterfly shape on the nose 
and cheeks or be unilateral, is often covered with telangiectic 
vessels, and may be slightly scaly. By stretching the skin nod- 
ules can sometimes be seen imbedded; it may invade both the 
scalp by the nucha and the mucous membrane of the mouth. 

Complications. — On the limbs secondary inflammatory acci- 
dents are more liable to occur, but not till after some years' 
duration of the disease. Among these may be mentioned sub- 
cutaneous nodes, which after a time are adherent to the skin on 
the one hand and the periosteum on the other; abscesses, 
periostitis, osteitis, caries, and necrosis occasionally occur, and 
the bones of the forearm and leg, and also those of the hands 
and toes, may become indurated and thickened, while more or 
less crippling of the joints may supervene from cicatricial 
atrophy of the skin and adhesion of tendons; such conditions 
would rarely occur except in those who were markedly 
strumous, and are not the direct effects of lupus. Erysipelas 
and lymphangitis are liable to occur at any time, and all these 
inflammatory complications may eventually, by the consequent 
obstruction to the lymphatic and blood flow, lead to elephan- 
tiasis of the legs, but very rarely of the arms. In Fischer's 
case, dermatolytic tumors formed on the thighs from similar 
causes. When erysipelas occurs on the face, chiefly as a sequel 
to the use of caustics, great improvement to the lupus often 
results, as I have several times witnessed. On the other hand, 
some of the cases of acute lupus before mentioned get attacks 
of recurrent lymphangitis, which, if not actually erysipelas, are 
indistinguishable from it, except that they seem to lead to ex- 

* /our. des Mai. Cutane'es, May number, vol. iii., 1891. Hardaway has 
published an interesting case which resembled the two diseases very 
closely, Trans, of Seventeenth Annual Meeting of A7ner. Derm. Assoc. , 
September, 1893. 



LUPUS VULGARIS. 769 

tension of the disease instead of its involution. Kaposi has 
called it erysipelas perstans, but it is now regarded as a tubercu- 
lous lymphangitis, and may be the sole manifestation of tu- 
berculous infection. 

Besides the complications described in lupus of the limbs in 
strumous subjects, enlargement, caseation, and suppuration of 
the glands in the neighborhood of the face may occur, and even 
chronic enlargement of the parotid. Leloir has shown that this 
lymphatic enlargement is often a real infection with tubercle 
bacilli, and not merely swelling, the result of irritation. The 
red lines often seen leading from the lupus patch after tu- 
berculin injections are also to be regarded as evidence of lym- 
phatic infection. 

Lupus papillomatosus * is not a true variety of lupus. Papil- 
lomatous outgrowth occurs as a complication of any chronic 
ulceration, but when not associated with tuberculosis is not 
called lupus. It is probably a product of pus cocci rather than 
of tubercle bacilli. In this condition papillary growths of 
granulation tissue, not true papillomata, are produced, and are 
usually covered with thick yellowish or greenish crusts. When 
these are removed the papillary easily bleeding growths are 
exposed. The extremities, especially the backs of the hands and 
feet, and buttocks are favorite positions for it, but an extreme 
development on the face is recorded by Morrow.f Possibly it 
was really Plastomycosis. 

Elephantiasis may complicate lupus when the infiltration 
blocks the lymphatic circulation. It is, in fact, a further devel- 
opment of L. hypertrophicus. 

Epithelioma is another more serious complication in lupus 
of long standing, which occurs in two per cent, of the cases 
(Leloir). It may develop in the lupus scar tissue, but it rarely, 
if ever, attacks the lupus tissue in my opinion. If on the face, 
it may penetrate into the mouth, but in whatever position the 

* Author's Atlas, Plates LXII., Fig. 2, and LXIIL, Fig. 3, and Hutchin- 
son's smaller Atlas, Plate LXXIX. 

f Amer. Jour. Cut. and Gen.-Ur. Dzs., vol. vi. (1888), pp. 361 and 401, 
"Tuberculosis Papillomatosa Cutis, and the Relation of Papilloma to 
Syphilis, Lupus, etc.," with colored plate; and in Morrow's Atlas, Plate 
LYXII. 

49 



770 DISEASES OF THE SKIN. 

life of the patient can only be saved by early and wide removal. 
It may be either fungating or ulcerating, and is said to occur 
chiefly in women. In a man, set. twenty-nine, the lupus had 
existed for twenty years, extending over a large part of the 
face, and over the right lower jaw an epitheliomatous growth 
the size of half a plum had developed three months before I 
saw him. The growth was freely removed by my colleague, Mr. 
Pollard, and six years afterwards another smaller growth 
formed lower down. This was also removed in 1896, I believe 
without recurrence. I have had another equally successful male 
case with no recurrence since June, 1894. The early de- 
velopment is not unusual. Bayha * noted four cases out of 
the forty-two he collected, and only one out of ten appeared 
to be cured after excision, the others recurring with fearful 
malignity, for lupus tissue seems to favor the rapid spread of 
the disease. Probably these cases either did not come under 
observation sufficiently early, or the removal was not wide 
enough. In a case of Audry's it supervened on a lupus of the 
bucco-pharyngeal mucous membrane, and of course nothing 
could be done. 

Among general complications may be mentioned, in addition 
to scrofula, chlorosis, emaciation, and phthisis, the last chiefly 
where the skin lesion is very extensive. Lespinnes,f from ob- 
servation of four cases in Leloir's clinic, describes a complica- 
tion which occurs sometimes in ulcerating lupus just before it 
breaks down. There is a sudden rise of temperature, immedi- 
ately followed by prostration of a typhoid character. There are 
gastro-intestinal and bronchial catarrh, and even endocarditis 
or other serous inflammation. All these symptoms come on 
simultaneously and resemble those produced by tuberculin in- 
jections. Leloir therefore inclines to the belief that the symp- 
toms are due to the absorption of similar products of bacillary 
action, and antiseptic local applications have been followed by 

* Much of Bayha's monograph is reproduced, with additional cases, 
illustrations, and remarks, in Hutchinson's Archives of Surgery, vol. ii. 
p. 138. See also Bidault's "These de Lille," 1886, and Karpinski's of 
Greifswald, 1891. My case was published in my Atlas, Plate LX. In 
Archivf. Derm u. Syph.< vol. lvii. (1901), p. 193, Ashihara gives a very 
complete survey and bibliography. Naegeli, in Virchow's Archzv, bd. 
cxlviii., gives forty-nine references. 

\Jour. des Mai. Cutane'es, vol. iii. (1891), p. 531. 



LUPUS VULGARIS. 771 

rapid subsidence of the symptoms in most cases, but general 
tuberculosis has resulted or permanent organic disease of the 
heart been left. Fortunately this complication is very rare. 

Lupus and other forms of tuberculosis of the skin may be 
complicated by syphilis. No law can be laid down as to what 
will be the result of this mixed infection. Some cases of ma- 
lignant syphilis have occurred in tubercular subjects, but it has 
also attacked apparently robust persons. In a case of Petrini 
de Galatz with lupus of the face and buttocks, the syphilid took 
the form of the small follicular syphilid, which is so like lichen 
scrofulosorum, but this was probably only a coincidence. In 
a case reported by Etienne the tuberculosis supervened on 
syphilis, the result was a general and enormous adenopathy. 
In Neisser's case of lupus and tubero-serpiginous syphilid the 
chief interest lay in the diagnosis. Walter Smith * met with a 
curious combination of symptoms in a girl of eighteen previ- 
ously healthy. Pulpy nodosities appeared first on the fingers, 
then psoriasis-like eruption on the body, which left scars; on 
the tip of the nose was undoubted ordinary nodular lupus which 
ulcerated; symmetrical exostoses on nose and fingers. He re- 
garded all the symptoms as tubercular manifestations. 

Mucous Membranes. — When it attacks the mucous membranes 
it begins near external orifices, and generally by extension of 
the disease from the neighboring skin, or it is at all events asso- 
ciated with skin lesions ; but it may be primary, and I have once 
seen it beginning on the gum of a strumous child of two years 
old with no lupus elsewhere. Max Bender collected 380 cases 
of lupus from Doutrelepont's clinic, and found the mucous 
membranes involved in 173, or 45.5 per cent., but in only 6 were 
the mucous membranes alone affected. He found, however, 
that the disease had commenced in the mucous membranes in 
31 per cent.; this is far more than is usually supposed. The 
mucous membrane of the nose was affected in 115 cases, of the 
lips in 43, of the palate in 31, the nasal duct in 24, the con- 
junctiva in 21, the larynx in 13, the tongue in 1, the rectum 
and vulva in 1. Audry goes much farther than this. He had 
all cases of face lupus examined, and in every instance there 
were deep lesions of the nasal mucous membranes, and he came 
to the conclusion that the nasal mucous membrane was the 
* Brit. four. Derm., vol. ix. (1897), p. 187. 



772 DISEASES OF THE SKIN. 

starting point for the immense majority of cases of lupus of 
the face. 

Its effects on the nose have been already described; on the 
mouth, extending inwards from the lips, granulating sores form 
on the inner side of the lips and on the gums, and generally 
project over the upper incisors; papillary growths are more 
frequent here than elsewhere and separate the gums from the 
teeth; stomatitis is present more or less, and produces the 
superficial grayish patches, similar to those so often seen in 
syphilitics. In a few cases, of which I have seen one, lym- 
phangiectodes of the mouth * has occurred with L. vulgaris 
of the skin. Punched-out ulcers on the hard palate are com- 
mon, but caries of the bones never ensues. The soft palate 
and pharynx may be notably affected as in tertiary syphilis, but 
adhesion of the soft palate to the pharynx is less common than 
in syphilis, the lesions of which, in other respects, the cicatrices 
closely resemble. Spontaneous healing may occur sometimes, 
but only after many years. The tongue is very rarely in- 
volved; in Leloir's case f it presented a verrucose condition. 
In the larynx it may affect the epiglottis extending from the 
buccal cavity, thence to the aryteno-epiglottidean folds, and 
to the other points of the larynx, and may affect the voice in 
various degrees; but no danger to life need be apprehended, 
nor any destruction of cartilages; in rare instances it is pri- 
mary in this part. It is occasionally primary on the con- 
junctiva, or it may have spread from the lachrymal duct or 
from the cheek on to the inside of the lower lid, and thence 
on to the eye, where it forms granulations and extends like a 
pannus over the cornea, and may completely cover it. In the 
ear it may spread along the external meatus up to the mem- 
brana tympani, which may be destroyed, and after various 
anomalies of hearing, fungating tumors may develop . on the 
meatus and occlude it; it is, however, very rare for the internal 
ear to be involved, which is reached by extension along the 
Eustachian tube. Cases have been reported of its existence in 
the uterus and vagina. 

Etiology. — Lupus is much more common in females than 
males — two to one is the accepted ratio in England, though, in 

* Author's Atlas, Plate LXXIV., Fig. 5. 
f International Atlas, Plate III. 



LUPUS VULGARIS. 773 

my experience, four to one would be nearer the mark. It 
seldom begins before three years of age, though C. Fox met 
with five cases in the first year of life. It is said to rarely begin 
after puberty, but it is by no means so rare as is usually stated, 
and one of the worst cases I have seen was a case of undoubted 
nodular lupus vulgaris, which began on the forehead of a lady 
when she was forty-six years old, and spread over the whole 
face, scalp, and part of the neck. There were also a few small 
foci on the limbs, but here it showed very little tendency to 
spread. Active interference only made it spread more rapidly. 
Her general health was good, and there was no evidence of 
phthisis or struma in herself or her family. Dr. Campbell 
Pope sent me a man in whom it began at sixty-three, and the 
patches multiplied until in three years there were twenty-one 
on the face and trunk. The patient was otherwise apparently 
healthy. I have also seen it in a lady, commencing when she 
was sixty-three. Although much more common among the 
poor, no class is exempt, but its frequency varies in different 
countries. It is more common on the Continent than in Great 
Britain, and almost rare in North America. While the patient 
is the subject of phthisis in a moderate number (eight in thirty- 
eight of Besnier's cases), I have been astonished, since I have 
inquired into it, at the large proportion of cases in which a his- 
tory of phthisis in one or more members of the family is ob- 
tainable; Hutchinson has made a similar observation. This 
does not hold good for America; according to Nevins Hyde 
of Chicago, in eighteen cases where the family history was ob- 
tainable, in only one was there a distinct phthisical history. 
The general health may be good, bad, or indifferent, but C. 
Fox * found that one-third of his cases had glandular enlarge- 
ment, fifteen per cent, had scrofulo-gummata, and eight per 
cent, joint or bone disease, and true L. vulgaris started in dif- 
ferent instances in caseating glands, diseased bone, and scrofu- 
lous gummata. 

While the majority of cases of direct inoculation of tubercle 
bacilli take the form of ulcers or L. verrucosus, which is par 
excellence " inoculation lupus," there is no doubt that nodular 
L. vulgaris also may arise occasionally from direct inoculation.! 

* Westminster Hospital Report, 1893. 

fW. Dubreuilh and Auche collected sixty cases of cutaneous inocula- 



774 DISEASES OF THE SKIN. 

In Lipp's case the lupus was supposed to have arisen from 
the consumptive mother kissing the child's face on which there 
were rhagades.* Jadassohn met with a case in which a butcher 
inoculated his finger with a tuberculous ulcer from an ox, and 
true lupus appeared higher up the arm; he relates another 
case which arose on the tattooed surface of a woman's arm — 
the ink was moistened with the operator's saliva. 

Dent records three cases in one family; they had all occu- 
pied the same bedroom, and two had slept together. I have had 
a case of a boy who had large symmetrical patches of lupus 
on the inner side of each knee, and auto-inoculation was proba- 
ble. Clement Lucas relates the case of an attendant on a lady 
who had lupus, who was herself attacked with it on her nose; 
also of a Jewish infant, where it appeared on the penis after 
ritual circumcision. Many instances of this are on record, the 
operator having been phthisical, but it is seldom that the result 
was a true nodular lupus. Thus, in a group of nine cases at 
Yalta from this cause, they nearly all had ulceration of the 
cicatrix four or five weeks after the operation; one had lym- 
phangitis, two died of consecutive pulmonary tuberculosis. 
Lucas' case of L. verrucosus, developing on the hand from hav- 
ing received a tooth wound on the fist, also illustrates the rule. 
Nevertheless, L. vulgaris of the lobes of the ears from piercing 
the ears has been several times recorded, Wolters' case from 
inoculating bacilli from sputum (footnote, p. 764) was said to 
be typical; and Corlett also had a case where the lesion began 
as a plaque on the forehead, then ulcerated, and the ulceration 
spread all over the face. L. vulgaris is seen occasionally in 
vaccination scars (see p. 525), herpes zoster scars, and those 
following an injury. Thus, in a woman of twenty-three, lupus 
developed on the scar of a cut on the nose, beginning very soon 
after the wound healed. Previous inflammation may favor the 
development and determine the position of the disease. All 
these modes are only the open door by which the tubercle 
bacillus gets in. Experimental corroboration of these sug- 

tion of tuberculosis. Ab.5. Ann. de Derm, et de Syph., vol. ii. (1891), 

P- 95- 

* At U. C. H., 1900, No. 74, a child of two-and-half of healthy stock was 
brought with a pin's-head spot of lupus on the cheek. She was often 
kissed by a woman who died of phthisis in the hospital. 



LUPUS VULGARIS. 775 

gestive clinical facts has been furnished by Leloir,* who, by 
taking large pieces of lupus tissue and placing them, with due 
precautions against error, in the peritoneal cavity of guinea- 
pigs, produced general tuberculosis. Leloir said lupus is proba- 
bly produced: 

I. By direct inoculation from without. II. Indirect inocula- 
tion by continuity from deep tuberculous foci. III. Inocula- 
tion by way of the lymphatics or veins passing through a 
tuberculous focus more or less remote. IV. Infection of 
hematic origin. V. Infection in utero. Methods I. and II. are 
most frequent, while V. is extremely rare, but a case recorded 
by Sabouraud lends support to the possibility of it. A child 
of a phthisical mother died when eleven days old, and abundant 
miliary tubercle was found in the liver and spleen, the only 
organs examined. 

The form which a tuberculosis of the skin takes is largely 
determined by: 1. The mode of invasion of the skin, i. e., from 
within, when it is more likely to be nodular, or without, when 
it will probably be verrucose or ulcerative. 2. Possibly the 
number of the bacilli inoculated and whether it is with or with- 
out pus cocci, although the suppositions fall short of proof. 
3. The kind of soil or constitutional proclivities of the individ- 
ual. Thus there can be no doubt that the so-called scrofulous 
predisposition very much favors the early suppuration and 
ulceration of the lupus. The scrofulous person is also much 
more likely to have caseating glands, and secondary lymphan- 
gitis, etc. A purely nodular lupus often occurs in an other- 
wise healthy person, and shows little tendency to ulcerate, and 
in some cases, not much to spread. 

Although lupus is often aggravated by exposure to cold, and 
is generally worse in winter, there is no reason to believe that 
it directly excites it. 

Multiple lupus very frequently follows specific fevers, espe- 
cially measles; tuberculous glands probably soften under its 
toxin, setting free the bacilli into the circulation. 

Thibierge records a case in which a quiescent lupus scar with 
some nodules was awakened to activity in thirteen pregnancies 
and during lactation, and then subsided until the next preg- 

*See also Eve's "Experiments on the Rabbit," Path. Trans., vol. 
xxxix. (1888), p. 363. 



776 DISEASES OF THE SKIN. 

nancy. Other instances of activity during pregnancy and lacta- 
tion are on record, but the effect is not constant, some cases 
having improved during pregnancy and got bad again after- 
wards. 

Pathology. — The lesions of lupus are due to a neoplasm of the 
granuloma class, consisting of a small cell infiltration which 
begins first in the deep part of the corium, and from thence 
gradually invades all the other skin structures. The cause of 
the process is now generally regarded as the irritative presence 
of tubercle bacilli. Koch first demonstrated the presence of 
bacilli, indistinguishable from tubercle bacilli, in lupus tissue, 
and the view that lupus is a chronic tuberculosis of the skin 
was greedily taken up, though Kaposi, Schwimmer, and some 
others strongly opposed such a theory. The bacilli exist in 
such very small numbers, one or two in a section perhaps, that 
they are often only to be found by careful examination of a 
large number of sections taken from the border of the growth. 
Cornil and Leloir, in a large number of sections taken from 
twelve cases, found only a single bacillus in a cell, and that 
from a case in which phthisis was present. It is strange that 
so much damage should arise from such a sparse distribution; 
but this may arise partly from the bacilli having perished in 
the older lupus tissue, though they are scanty even in the 
growing edge. In addition to the bacilli, all structures that are 
found in miliary tubercle are present in lupus, and these are 
particularly abundant in L. papillomatosus. Further confirma- 
tion that lupus is a tuberculosis of the skin is found in the vio- 
lent local and general reaction to injections of the old tu- 
berculin. It is, however, certainly at most a local tuberculosis, 
without any tendency to generalize. 

Anatomy.— This has been investigated by Virchow, Auspitz. Kaposi, 
and a host of more modern observers. Although the modern nomen- 
clature and interpretation are somewhat different, the cells being called 
plasma (Unna),* epithelioid, etc., the description of Kaposi is still one of 

* Unna's " Histopathology," p. 574, contains an elaborate description of 
this interpretation of the histology of lupus. Plasma cells (Unna) are 
more or less round, oval, or angular in shape, with a round nucleus gen- 
erally situated eccentrically. Their protoplasm is granular (granoplasma), 
and their nucleus contains, in addition to a nucleolus and a chromatin 
network, some five or more coarse granules arranged about the periphery. 
These details are brought out by special staining methods : polychrome, 



LUPUS VULGARIS. 



777 



the best accounts, and as it agrees with my own observations, it is that 
mainly followed here. Taking first a single recent general nodule, it is 
found imbedded in the deeper part of the corium, sharply defined from 
the rest of the cutis, and bounded by a dense fibrous tissue, the skin 
structures above the nodule remaining healthy. 

The nodule has a framework consisting of a delicate fibrous reticulum 
with abundant vessels, the larger meshes of which are filled with round 




Fig. 



■in., obj. w. a. 



-Lupus vulgaris from nates. 2-in. oc. f- 

a, thickened rete mucosum ; b. b, b, round-cell infiltration separating 
fibers of corium ; c, blood-vessel ; d, d, nodules. 



cells, with sharply defined, strongly staining nuclei, while the small 
meshes contain also some smaller cells, and many free nuclei. Giant 
cells are also present in varying numbers, but their importance has dimin- 
ished, since they are now known not to be characteristic of tubercle, as 

methyl-blue and glycerin ether (Unna), or methyl-green-pyronine and 
resorcin (Pappenheim). [Abs. of good paper by Pappenheim, etc., in 
Brit. Jour. Der?n., vol. xiv. (1902) p. 147.] According to Unna and his 
followers, these plasma cells originate from fixed connective tissue cells 
(histiogenetic), but von Marschalko and others contend they are derived 
from the lymphocytes of the blood (hematogenetic). Plasma cells occur 
in lupus vulgaris, syphilids, etc. 



77 8 



DISEASES OF THE SKIN. 



they were thought to be when Friedlander, previous to Koch's discovery, 
advanced the theory, founded on their presence in lupus tissue, that it 
was a tuberculosis of the skin. 

As the cells in the center of the nodules increase in numbers, the vas- 
cular supply is interfered with, and fatty degeneration and disintegration 
ensue in that part, and by extension of this necrobiosis, ultimately nearly 
the whole nodule is absorbed or ulcerates, though at the periphery the 
new products may, according to Lang and Kaposi, organize into con- 
nective tissue and cicatrize, differing in this respect from leprosy and 
syphilis. 

When this fibroid formation is highly developed it produces what Nor- 
man Walker calls fibroid lupus. 

When the foci are numerous, as they generally are, they extend periph- 
erally in the course of the vessels, coalesce, and gradually involve the 




Fig. 42. — Lupus vulgaris from same section as Fig. 33. $ obj. Powell, 2- 
in. oc. a, fibro-cellular reticulum ; b, b, multi-nucleated giant cells. 



whole corium of the region affected. In the epidermis, which soon be- 
comes affected, the rete cells undergo proliferation and fatty degenera- 
tion ; there is downgrowth of the interpapillary processes on the one 
hand, and encroachment of the lupus infiltration in some parts on the 
other, obliterating the boundary line between the palisade stratum of the 
rete and the papillary layer of the corium. More or less desquamation 
occurs, and by this means, or by suppuration, the lupus infiltration is laid 
bare and ulcerates. Norman Walker disputes the justice of calling the 
process ulceration, as he says the surface is always more or less covered 
with epithelium, though often swollen and distorted, and he therefore 
wishes to substitute the word catarrhal, as it is comparable to the lung 
process. Although there is a certain amount of truth in this, the term 
chosen is not an acceptable one, and suppurative lupus is truthful and 
less objectionable. 

Similar changes occur in the epithelia of the sweat and sebaceous 
glands and hair follicles; hence ensue atrophy of the papilla, falling out 



LUPUS VULGARIS. 



779 



of the hair, occlusion of the gland ducts, and consequent retention of 
secretion, so that milium-like bodies are imbedded here and there in the 
corium. According to Lang, Stilling, and Jarisch, the reticulum, the 
vessels, and part of the infiltration are formed by proliferation of the 
cells of the vessel walls and lymph channels, and consequent outgrowths 
from them, while the rest of the infiltration consists of emigrant cells 
from the vessels. As occasional features may be mentioned general 
hyperplasia of the whole of the tissues, resulting in elephantiasis, or the 
papillae alone may enlarge enormously, and a verrucose condition be pro- 
duced. Sometimes the epithelial proliferation is the striking feature, and 
that of the rete, follicle, and sweat glands may coalesce, and form a sort 
of network, permeating the lupus infiltration. It is in such cases that 
epithelioma may develop. 

Diagnosis. — The diagnosis is easy when " apple jelly " nodules 
imbedded in the skin are present, or raised above it; when there 
are one or more inflammatory-looking infiltrations, more or 
less raised above the surface, moderately scaly, with a well- 
defined edge, and perhaps some of the aforesaid nodules near 
it; when with this there is more or less scarring, either atrophic 
or ulcerative, the latter chiefly where the skin and mucous 
membrane join; when, too, in such cases the disease runs an 
extremely indolent course and occurs in a child or young per- 
son, or if in an adult, the disease dates from childhood. 

Use of Glass Pressure. — In a very early stage, when there is 
only a single nodule deep in the skin, or in a slight recurrence 
in a scar, lupus can be distinguished from an inflammtaory 
papule by pressing on it with glass, when an inflammatory 
lesion is quite obliterated, while a lupus nodule with the blood 
squeezed out leaves a yellow spot still visible through the glass. 

Whenever there is scarring present, with an infiltrating erup- 
tion, the diagnosis in a young, or at all events not elderly per- 
son, practically lies between three diseases, viz., lupus, scrofulo- 
dermia, and gummatous infiltration from syphilis, leprosy being 
too rare in this country to need much discussion. 

In a gummatous syphilid the disease almost always is acquired 
in adult life, ulcerates readily, spontaneously, and often deeply, 
with a sharp edge, and runs a comparatively rapid course, do- 
ing more damage in a few weeks or months than lupus will 
produce in as many years. In lupus the disease generally be- 
gins in early life, runs a very slow course, and ulcerates only 
on provocation or when near a mucous membrane, and then 



780 DISEASES OF THE SKIN. 

superficially, and generally with a rounded edge; the secre- 
tion is scanty and inoffensive, the crusts thin and brownish, 
except in strumous subjects. Then lupus never implicates the 
bones of the face,* while syphilis often does, and the crusts in 
the latter are abundant and greenish, and the secretion of- 
fensive. 

Corroborative evidence of past or present syphilis is nearly 
always obtainable on the one hand, while this is negative in 
lupus. If, after taking everything into consideration, doubt 
still remains, a tentative treatment with iodid of potassium and 
mercury for a week or two will decide the matter, marked im- 
provement resulting in syphilis, while lupus is unaffected, or 
only to a slight degree. 

In scrofiilodermia caseous glands, or the scars left by them, 
are present, and the disease consists in a chronic dermatitis 
spreading from the softened glands; there is more or less 
ulceration, probably sinuses, and soft red undermined skin, but 
no translucent brownish tubercles in or near the infiltration, 
and there is probably other evidence of the so-called strumous 
diathesis. With such symptoms present the diagnosis is easy; 
but sometimes lupus also starts from caseous glands, or at 
all events may develop in a notably strumous patient, and the 
two conditions merge into one another; the diagnosis may 
therefore be difficult, but is fortunately not then of practical 
importance, and does not modify the treatment. 

In leprosy it is only when the disease is in an early stage that 
any difficulty could arise. If there were any anesthesia present, 
this, with the history of the patient's having been in a leprous 
district, would at once decide the diagnosis; later on the other 
characteristic symptoms of leprosy would be present. 

Some cases of multiple lupus of the limbs, where the disease 
has involuted in the center and left rings, are remarkably like 
the early stage of some maculo-anesthetic cases of leprosy 
without any other symptom. Leprosy may also begin as rings 
of the same color and elevation with an atrophically cicatricial 
center. In the latter, however, there is always partial anes- 
thesia in the center, sometimes preceded by hyperesthesia, but 
the difficulty lies in the fact that the dysesthesia is not always 

* They sometimes fall out from want of support by the destroyed soft 
tissues. 



LUPUS VULGARIS. 781 

pronounced, and with a very young or nervous patient, state- 
ments on relative sensibility of parts are not reliable. Possibly 
assistance might be obtained from the enlargement of the rings 
of the lepra being much more rapid. All doubt would be re- 
moved as the leprosy developed further, and difficulties would 
only arise when the patient had lived in a leprosy district. 

Psoriasis. — A few cases closely resemble psoriasis. The in- 
filtration is greater in lupus, the scaling less, and not in silvery 
crusts, the patches are comparatively stationary. Search may 
reveal more typical lupus patches, and there is more or less 
scarring in an old lupus patch, a feature which is infinitely rare 
in psoriasis. In a patient of mine, a man of forty-five, there was 
a four-inch patch on the chest which had been forming for 
twenty years, very slowly enlarging; it had been repeatedly 
treated for psoriasis. There were several smaller and more 
recent lesions, one above the clavicle showed typical lupus 
nodules. 

Lupus sometimes closely resembles squamous eczema. The 
length of time that the lupus has existed in a very limited area, 
its sharply defined and raised border, the greater amount of 
infiltration of the skin, its having been dry throughout its 
course, while it has not varied in intensity to a notable extent, 
and its tendency to scar formation, are all points in which it 
contrasts with an eczema patch. 

In people past middle age epithelioma might be confounded 
with lupus. The age at which the disease began, the position 
of epithelioma, its painfulness, its limitation to a small area, the 
induration round the infiltration or ulcer, are all points of dis- 
tinction. The depth of the ulcer also is usually greater, the 
edge raised, everted, and hard, the surface uneven, and the 
more rapid progress and the involvement of neighboring 
glands mark the malignant form of disease. The occasional 
supervention of epithelioma on lupus of long standing has al- 
ready been mentioned. For the distinction from rodent ulcer 
see that disease. 

L. erythematosus is distinguished from L. vulgaris by the more 
superficial and less raised character of the eruption, the ab- 
sence of ulceration, and the absence of nodules or papules in 
or near the patch; moreover, it nearly always begins much 
later than vulgaris, and is often symmetrical. It generally pro- 



782 DISEASES OF THE SKIN. 

gresses more rapidly than L. vulgaris, and the sebaceous 
glands are often conspicuously involved in erythematous lupus, 
but not in L. vulgaris. As has been stated already, however, 
the differences in some cases are by no means striking, and 
careful consideration of every point is required. 

In cases of doubt, where the diagnosis is important, Koch's 
old tuberculin injections may be employed; whatever its short- 
comings as a curative treatment, there is no doubt that it may 
sometimes prove a valuable aid in diagnosis.* Two milli- 
grams (.002) may be first tried, and then .005 or even .01 em- 
ployed, and the smaller the dose which produces local and gen- 
eral reaction the more strongly would it speak for L. vulgaris; 
a full dose like .01 may produce slight local reaction in a L. 
erythematosus, but not in syphilis, rodent ulcer, or epithelioma. 
It is not of any discriminating service in lepra or scrofuloder- 
mia; from the latter, however, the diagnosis is of more 
academic than practical importance, and lepra may react to it 
so violently that if this disease is suspected it should not be 
employed. 

When the disease is reduced to a few nodules, doubts occa- 
sionally arise as to whether a red spot is a lupus nodule or not; 
in such cases, glass pressure (diascopy or phaneroscopy), as 
recommended by Liebreich and Unna, may be employed. The 
blood is pressed out of the vessels, and an inflammatory spot 
would disappear entirely, while a brownish dot would still be 
left in a lupus nodule. In rare instances it might help a de- 
cision in a very early lupus spot. A watch glass or a large 
convex lens is a convenient means of applying the method, but 
a pleximeter-shaped instrument of glass is sold for the pur- 
pose. Unna claims that nodules in scar tissue which cannot 
be seen in the ordinary way may be brought into view by paint- 
ing the skin with carbolic acid, which makes it transparent. 
Oil of cloves or camphor chloral is added to mitigate the pain 
of the application. Injections of old tuberculin reveal the nod- 
ules even more effectually. 

* The above appeared in the second edition of this work. More recently 
(January 1900), Neisser emphasizes and strongly recommends the old 
tuberculin both for diagnosis and treatment in suitable cases. McCall 
Anderson corroborates from his own experience in the Lancet, June 16, 
1900, p. 1703. 



LUPUS VULGARIS. 783 

Prognosis. — This depends on the age of the patient, the ex- 
tent and duration of the disease, especially with regard to mul- 
tiple foci, and the amount and character of the treatment. It 
is always a chronic, obstinate disease, tending to recur again 
and again, after apparent complete removal, but, when of lim- 
ited area, complete cure may be effected by perseverance; the 
older the patient the better is the chance of permanent removal, 
durable cures in childhood being of very rare occurrence, un- 
less the diseased area is of sufficiently limited extent, and in 
such a position that excision or other radical measure can be 
employed. 

Treatment. — While no internal treatment alone can be relied 
on for removing a lupus patch, much may be done to retard 
the progress of the disease, and favor involution rather than 
ulceration, also to delay, and even sometimes to prevent, the 
recurrence after the removal of the infiltration by local means. 

The only agent which has a direct effect on lupus tissue when 
given by the mouth is thyroid extract, or its derivatives, first 
suggested by Byrom Bramwell, and it is in my opinion the most 
important adjuvant to surgical or other local means that we 
possess. It should be given after as much as possible of the 
disease has been removed by local measures, beginning with 
five grains of the dried gland. Tabloids are generally the most 
convenient form; after a fortnight ten grains of the gland may 
be given, and if the patient is tolerant, in another fortnight it 
may be raised to fifteen grains per diem. 

As it has to be given for a long period, a year or more, it is 
not advisable to give more than this, and some patients cannot 
take more than two tabloids a day. When once tolerance is 
established it can be taken for years without inconvenience or 
any symptom except that the patient gets thinner, but appar- 
ently only loses superfluous fat. If, however, the dose is too 
large at first, or a sufficient interval between the increments of 
the dose is not observed, the patient will be upset, sometimes 
seriously, with the well-known symptoms of thyroidism.* It 
may also be given with advantage where the disease is too 

*Thyroidism may be induced in sucking infants if the mother is taking 
the drug. In one of my cases, while there was loss of weight at first, 
subsequently there was an actual increase. In this case, with a most ex- 
tensive ulcerating lupus a very large part of the disease healed soundly. 



784 DISEASES OF THE SKIN. 

extensive for local interference, or where, from its locality or 
for other reasons, efficient local treatment cannot be employed. 
Although I have never seen a cure under it alone, very consid- 
erable and striking improvement can often be obtained. 

All measures, also, that tend to improve the general health 
should be adopted; good hygiene, in every sense of the word, 
as far as it can be secured, should hold a high place, while the 
patient should be carefully guarded against external irritants, 
such as cold winds, sudden alterations of temperature, and the 
like. Coming of a phthisical stock, as so many do in this 
country, and the not infrequent association with evident struma, 
cod-liver oil in full doses steadily persevered in, but with oc- 
casional intermissions, holds a high place. Iodin, either with 
the oil in grain doses, three drop doses of the tincture, or the 
potassium salt, or the syrup of the iodid of iron, is also of 
value, but only where thyroid is contra-indicated. 

Improvement in assimilation is the great aim, and therefore 
attention must be paid to the condition of the alimentary canal, 
and a nutritious dietary of easy digestion drawn up when the 
digestive powers are weak. In proportion as the general health 
is good, and the patient often seems to be quite robust, is in- 
ternal treatment of minor importance. 

Injection Treatment. — Ordinary internal medication having 
such a limited scope, men's hopes of a specific being at last dis- 
covered were raised to the highest pitch when the marvelous 
selective effect on lupus tissue of Koch's tuberculin, admin- 
istered hypodermically, was first demonstrated. Disappoint- 
ment has been proportionately great, now that it is shown that 
the good effect is for most cases only temporary; and although 
the new, or TR. tuberculin, gives similar results without the 
pains and penalties of the old toxin, the frequent failure to 
obtain a permanent cure has made most people throw it aside 
altogether. I am of opinion, however, from considerable ex- 
perience in its use, that there is still a place for it in lupus 
therapeutics, although unfortunately a small and subsidiary 
one. The improvement is greatest in the ulcerative form in 
the young, and least in the purely nodular form in adults, in 
which sometimes the effect is only trifling. 

The mode of administration is given under Syphilis. More 
rapid, and I think more permanent, results can be obtained by 



LUPUS VULGARIS. 785 

local injections, i. e., injecting the fluid close to the lupus patch 
when that is accessible, and it is sometimes practically the only 
means of reaching otherwise inaccessible mucous membrane 
disease. Before commencing local injections the patient's sus- 
ceptibility should be tested by the minimal general injections. 

Another use for it is that after as much lupus tissue as possi- 
ble has been removed by erasion and the subsequent applica- 
tion of carbolic acid, or other similar application, injections of 
tuberculin, in the back first, and later locally, appear to remove 
some of the lupus tissue which could not be reached from 
without, and thus assists in securing a longer freedom from 
recurrence and a larger amount of permanent cure. 

One thing, however, it will do better than other medical or 
surgical measures have been able to effect, viz., remove the 
fibroid thickening * which is so often present when lupus affects 
the lip or other place where there is lax tissue. The hyper- 
trophic scar tissue of lupus (the lupus fibroma of Unna) may 
also be flattened down by it, sometimes revealing as it does so 
lupus nodules hitherto concealed. Thiosinamin and mercurial 
injections have also been used advantageously for this sec- 
ondary thickening. While, therefore, tuberculin still has a 
place in lupus therapeutics, the time, trouble, and expense on 
the one hand, and the various other means at our disposal en- 
croaching on its domain in various directions on the other, 
combine to limit its use to a comparatively small sphere of 
action. 

The details of the method of its administration are given in 
the Appendix of Formulae (Lupus Therapeutics). 

Since tuberculin, injections of other substances have been ad- 
vocated: cantharidinate of potash by A. Liebreich; chlorid of 
zinc injections by Lannelongue; thiosinamin by Hans Hebra; 
dog's serum because of its germicide action on the tubercle 
bacillus; calomel and perchlorid of mercury injections. None 
of these, apparently, have come to stay, except, perhaps, the 
mercurial salts for a small number of cases. Their painfulness 
would render them inapplicable to children, while the dangers 

* A marked example of this was that of a patient of mine treated by 
my friend Dr. Heron in Victoria Park Hospital for Consumption, when 
tuberculin first arrived in England. Although the nodular lupus returned, 
the fibromatous thickening did not do so. 

50 



786 DISEASES OF THE SKIN. 

of injecting insoluble salts of mercury are set forth in the 
treatment for syphilis. While acknowledging their power in 
absorbing granulation tissue, I should not admit so dangerous 
a remedy into my armamentarium while less risky treatment is 
available; soluble salts of mercury are less dangerous. It is 
probable that the tubercle bacilli are not killed by the mercury. 

Local Treatment. — It follows from what has been said that 
local measures are always necessary, and, as in all obstinate 
diseases, the number recommended is legion. I propose to 
mention only those that I have reason to speak well of, and to 
point out their indications and limitations. They may be 
classed under surgical, medical, and the light treatment. 

The surgical operations are: i. Excision; 2. Erasion; 3. 
Scarification; and, 4. The galvano- or Paquelin's cautery. 

Excision. — Whenever the position, e. g., the nose, or the 
extent or multiple foci of the disease do not contra-indicate it, 
there can be no doubt that excision extending about a quarter 
of an inch beyond the disease offers the best chance of a radical 
cure, often in one operation. Where the disease is tolerably 
recent and is of small extent, the patch may often be excised 
and primary union of the wound obtained with a linear, and 
therefore the minimum of scar. Where the position or extent 
do not allow of this, the wound left may be filled up by 
Thiersch grafts, or the resources of plastic surgery may be 
called upon. There is scarcely any limit to the operation on 
the limbs if there is only one patch, but on the face it may be 
otherwise, and the patient's consent is often withheld. 

Erasion may be used for large surfaces, or where the patient 
refuses excision, or for awkward positions, such as the orbit 
and nose. The instruments used are either Volkmann's sharp' 
spoon or the ringed curette (Fig. 43). Except for minute foci 
I use the curette. The diseased tissue is scraped away at first 
readily, but the instrument should be used vigorously at the 
base and edges of the disease, until the resistance of the 
healthy as compared to the diseased tissue is evident to the 
touch. In cases of long standing, owing to the diseased tissue* 
pocketing in the meshes of fibrous tissue at the base, and per- 
meating into the healthy area beyond the visible disease, the 
result soon after healing is seen to be imperfect, nodules of 
lupus showing up at once or some time after healing, and vari- 



LUPUS VULGARIS. 787 

ous supplementary measures are employed both at the time 
of operation and afterwards to reduce these recurrences to a 
minimum. At the time of operation the base may be freely 
scarified, and iodoform or strong carbolic acid applied freely. 
The action of the latter is superficial, but being liquid it pene- 
trates into interstices, and has the advantage of anesthetizing 
the wound after the first minute of application. I generally use 
a bundle of matches tied together and press firmly. The wound 
heals rapidly with a boric acid ointment, lotions giving so much 
pain each time they are changed. Anderson recommends rub- 
bing the surface of the wound after erasion with potassa fusa, 
and after a few seconds neutralizing with dilute acetic acid. 
Strong sulphuric acid neutralized with bicarbonate of soda is a 
similar application. Schlapoverski rubs the wound with solid 
nitrate of silver, and then covers it with collodion and ten per 
cent, iodoform; a chemical action takes place, and the caustic 
action is intensified. Chlorid of zinc solution, forty grains to 
the ounce, swabbed for a moment or two, and pyrogallic acid 
bandaged on, have also been strongly recommended; but the 
last three caustics give much pain for several hours after the 
operation, and I prefer the carbolic acid. The supplementary 
means after operation are tuberculin injections, or the adminis- 
tration of thyroid extract. The latter is the one I now chiefly 
use on account of its facility. The patient should be warned 
that for thorough success the erasion operation must be fol- 
lowed up by attacking the nodules as soon as they appear, 
otherwise in a year or two the patient will very likely be as bad 
as before. Each nodule should be scooped out with Vidal's 
knife, a small scoop, or drilled out with a pointed piece of hard 
wood dipped in the fuming acid nitrate of mercury, or, if they 
are very numerous, multiple scarification, after freezing the part 
with chlorid of ethyl or methyl, may be employed until the 
number of nodules is reduced. By perseverance in this way, 
at the same time continuing thyroid extract, very gratifying 
results may be obtained, and unless the surface is very large, 
permanent cure often results. Where repeated erasion has 
been used a seamed scar sometimes results, but this may be 
improved by time, by the application of mercurial plasters of 
Vigo, Vidal, or Unna, and by thiosinamin injections in the 
neighborhood, as described under keloid, or finally by shaving 



7 88 DISEASES OF THE SKIN. 

off the projections with a scalpel and applying Thiersch grafts, 
or by multiple scarification. There is some ground also for 
supposing that if the wound is kept aseptic during healing, 
hypertrophic scarring will be avoided. 

Multiple scarification may be carried out with either a scalpel, 
or preferably a Vidal's knife (Fig. 44), for a small area, or for 




Fig. 43. — Curette for scraping lupus. 

a larger patch by a sheaf of blades, of which there are several 
patterns, but Pick's (Fig. 45) is one of the best. The operation 
can be done under general or local anesthesia, and is suitable 
for small areas on the face, where a neat smooth thin scar is of 
the highest importance, and no other operation can compare 
with it in this respect. It appears to act by dividing large num- 
bers of vessels, and so starving out the neoplasm, but its scope 
is much limited by the necessity of the repetition of the scari- 
fication a large number of times, twenty or thirty or more in 



fcc 



Fig. 44. — Vidal's knife. 

some cases. The incisions should be made close to each other, 
and then another series at right angles, " cross-hatching," as it 
is called. Increased efficacy is obtained by immediately dab- 
bing the cut surface with carbolic acid. Nodular lupus of the 
end of the nose and upper lip is often best treated in this way. 
Not more than three weeks or a month should elapse between 
the operations in most cases. Multiple scarification may also 
be used immediately after erasion, at the borders of an acutely 
ulcerating lupus when erasion is contra-indicated, and to im- 
prove a hypertrophied scar. 

Multiple Puncture finds its chief advocate in Veiel of Cann- 
stadt, who devised a special instrument to facilitate its per- 
formance, which may also be used to supplement scraping. It 
is inferior as a primary treatment to both scraping and scarifi- 
cation. 



LUPUS VULGARIS. 



789 



The Galvanic, or Paquelins Cautery, is used either to totally 
destroy the new growth, or as a more thorough linear scarifi- 
cation method, and has some strong advocates, notably Bes- 
nier and Hutchinson, but it has the disadvantage of burning 
both sound and unsound skin with equal facility, and the sense 
of touch in recognizing the difference is unavailable, and a 
valuable means of thus judging how much to do is lost. Bes- 
nier, however, does not admit this. It is, in my practice, lim- 




Fig. 45. — Pick's lupus scarifier and multiple puncture instrument. 
A, B, closed for use ; C open for cleansing. 



ited to recurrent nodules, and to lupus of the mucous mem- 
branes, where it is valuable for preventing bleeding. 

Lustgarten and Gartner advocate Electrolysis, employing 
bright plates for the negative electrode, with twenty-four 
Leclanche cells. Jackson of New York is also in favor of this, 
but employs a coarse needle instead of a plate for the negative 
electrode. I have used this last method, independently, for 
cases where there were only a few recurrent nodules on the 
face, and for this purpose can speak in favor of the plan. 

Phototherapy. — Of recent years the therapeutic effects ob- 
tained by exposure to different sources of light have been em- 
ployed so successfully in lupus treatment that phototherapy 
bids fair to supersede many of the older methods in a large 
proportion of cases. They come under Finsen rays and 
Rontgen rays. 

In the Finsen Method sunlight where it is available, or in its 
absence the electric arc light, is concentrated by means of ap- 
paratus which cuts off the heat rays and leaves only the 
actinic, viz., the blue, violet, and ultra-violet rays to act upon 
the diseased tissue, from which the blood must be pressed out, 



790 DISEASES OF THE SKIN. 

as the red corpuscles in the skin prevent the deep action of the 
rays. 

Finsen's original apparatus was too cumbrous, expensive, 
and tedious in its application for private use, but the practica- 
bility of the method has been much extended by the lamp in- 
vented by Lortet and Genoud of Lyons, and its various imita- 
tions or modifications. In these the light is not brought to a 
focus, but the patient is brought close to the light before the 
rays diverge. By them also the time of exposure has been 
shortened to a quarter of an hour or so, the patient himself 
pressing against the rock crystal of the lens chamber to remove 
the blood from the part instead of a nurse being required. 
Even this time of exposure may be shortened, Bang of Copen- 
hagen having found that iron electrodes acted more rapidly 
than carbon ones; but they are said to lack penetrating power, 
and are not so suitable for lupus as carbon electrodes. Both 
the Lortet-Genoud and the Bang lamps require a current of 
cold water through the apparatus, which would otherwise be- 
come too hot and burn the patient. Broca and Chatin have in- 
vented an apparatus with the positive electrode metallic and 
the negative of carbon, where no cooling is required, and have 
an improved method of compression. In fact, modifications are 
continually being made in these portable lamps, which are 
worked from the ordinary mains, the continuous current being 
preferable. It is only necessary, therefore, to indicate the 
scope and effects of the electric arc treatment, whatever may 
be the construction of the lamp employed. 

The chief advantages are the painlessness of the treatment 
and its excellent cosmetic effect, the scar being thin, smooth, 
and uniform, and to these Leredde adds its homogeneity and 
penetrating power. 

The disadvantages are the small area treated at each ex- 
posure and hence the long time required, the exposures being 
usually very numerous, so that in a large area they may run 
into hundreds. 

No effect is seen at first, but after from twelve to forty-eight 
hours inflammatory action sets in with redness, swelling, and 
sometimes bullae, or oozing of the part directly exposed to the 
rays, and this inflammation is allowed to settle down or sub- 
dued with zinc ointment before the exposure is renewed. 



LUPUS VULGARIS. 



791 



The Finsen treatment * is not applicable to lupus of the 
mucous surfaces or to ulcerating or vegetating lupus, as to 
apply it successfully the part must be dry and the lens pressed 
hard against the part. If by radiotherapy or other means, e. g., 
permanganate of potash, an ulcerating lupus can be dried up, 
then the Finsen treatment can, if thought desirable, be carried 
out to the conclusion of the case. Its most successful appli- 
cation is to a dry lupus of the face, in which it cures with the 
minimum of scar, and when not very extensive, in a moderate 
number, say fifty to eighty exposures. 

On the limbs, surgical methods can generally be employed 
more rapidly and therefore more advantageously, since the 
character of the scar is less important. Local injections of 
tuberculin also have a good place in such cases. 

Like all other methods of treatment the cases must be fol- 
lowed up and recurrences dealt with at once, and only on these 
conditions can permanence of result be obtained, and it is obvi- 
ous, therefore, that the method is still far from perfect, but 
time and experience will no doubt lead to further improve- 
ments both in technique and apparatus. The Copenhagen 
school claim to get a deeper action with their original ap- 
paratus than with the Lortet-Genoud and similar models, but 
French workers are not of this opinion. They consider that 
the depth of action depends chiefly on the compression being 
sufficient to render the part operated on quite bloodless. 

In the Rbntgen Rays treatment, or radiotherapy, the diseased 
area is exposed to the rays of a Crookes tube of not less than 
6-inch spark gap for ten minutes daily, at 4 to 5 inches from 
the lamp, with a current of 4 amperes, a jet mercury interrupter, 
and a 10- or 12-inch coil. The healthy skin is protected by 
wearing a mask covered with lead foil, from which a piece is 
cut out corresponding with the diseased area; after six to 
twenty exposures inflammatory reaction is set up, when pro- 
nounced closely resembling that produced by the old tu- 
berculin treatment, including the radiating red lines in the 

* For further testimony in favor of Finsen's treatment see Discussion 
at the Paris Internat. Cong., Derm. Sect., 1900, at the annual meeting 
Brit. Med. Assoc, 1901, in Brit. Jour. Derm., vol. xiii., 1901. Leredde 
and Pautrier and others, Annates de Derm, et de Syfth., vol. iii. (1902;, 
pp. 327, 329, etc. 



792 DISEASES OF THE SKIN. 

course of the lymphatics. The lupus area becomes deep red, 
swells up, and exudes a serous fluid, breaking down into a raw 
surface, which takes three or four weeks to heal under boric 
acid ointment and europhen. Then the process is repeated, 
and ultimately sound cicatrization results, also smooth and 
thin, like that of the Finsen treatment in most cases, provided 
the reaction has not gone too far. Some think that the ex- 
posures should be stopped before there is decided reaction, but 
then the result is very imperfect. On the other hand, it is not 
always possible to regulate the exposures to the exact amount 
of reaction desired, the inflammation progressing sometimes 
for two or three weeks after the exposures have been stopped 
on the production of a very moderate erythema, and then 
ulceration may be produced which takes weeks or months to 
heal. Besides controllable conditions, such as the spark length 
of the tube, not less than six inches, the time of each exposure 
ten to twenty minutes, and the proximity of the tube best at 
four inches, there remain uncontrollable elements, such as 
idiosyncrasy of the patient, and peculiarities in certain tubes 
which cannot always be ascertained beforehand. 

It is this want of control that is the chief drawback, and 
Morris and Dore think the scar is not so good as that of the 
Finsen method, but this has not been my experience, which is 
very favorable to radiography, except as regards perfect con- 
trol as to the amount of effect produced. On the other hand, 
it can be used over a much larger area at a time than the 
Finsen, the course of treatment is usually shorter, ulcerating 
lupus usually heals well and soundly, and mucous cavities can 
be treated effectually. Probably it is not so reliable in deep- 
seated lupus. In some cases the two methods might be com- 
bined with advantage. Like all other methods, many repeti- 
tions are required. 

High Frequency Currents, as first used by D'Arsonval, have 
been used with success in lupus by Oudin, Brocq, and others, 
and the action is said to be similar to that of the Rontgen rays, 
but their advantages over the preceding methods have not been 
proved for L. vulgaris, but they will be further reverted to 
under L. erythematosus. 

Radium. — This rare and expensive element is said to give 
off emanations which affect lupus, and Danlos has experi- 



LUPUS VULGARIS. 793 

mented with it with some good results, but at present it is more 
of a curiosity than a practical method. A small quantity of the 
chlorid diluted with chlorid of barium is inclosed in a caout- 
chouc bag, and fastened to the diseased area. It has been used 
in lupus erythematosus with some benefit. 

Hot Air Currents even up to 300 C. on the one hand, and 
freezing with ethyl or methyl chlorid on the other, have had 
advocates, but have not had enough success to establish them 
as generally recognized means of treatment. 

Medical Methods of Local Treatment. — They may all be divided 
into two classes: (1) those which protect the part or diminish 
hyperemia, and so favor involution; (2) those which destroy the 
diseased tissue. Those of the first class have only a limited 
sphere of usefulness, but they are often serviceable in paving 
the way to more radical measures, which it is seldom judicious 
to urge upon the patient without some preliminary treatment. 
Calamin lotion, frequently and perseveringly applied, is one that 
is useful at first for lesions on the face with signs of active 
inflammation, but which are not actually ulcerating; it lessens 
hyperemia, partially conceals the eruption, and some degree 
of involution is often effected. Mercurial plasters, the em- 
plastrum Vigo, or Vidal's emplastrum rubrum (Plasters, F. 6), 
may often be applied at night, and are very valuable adjuncts. 

The inunction of simple ointments or soft soap, caoutchouc 
coverings, and most of the plasters recommended, soften and 
facilitate the removal of the scales or crusts, and pave the way 
for more energetic treatment. Brooke's ointment (Lupus 
Therapeutics, F. 1), acts in a similar direction, and produces 
a certain amount of involution if firmly rubbed in night and 
morning for some minutes. If the skin becomes broken, a 
milder antiseptic ointment, such as boric acid, should be ap- 
plied till it is sound again. A formula I have found useful is 
iodoform gr. 10, creolin TTLiij, lanolin ov, parolein or pure heavy 
paraffin oil oiij. The disagreeable odor of iodoform is favora- 
bly modified by the creolin. It should be rubbed in firmly, but 
not briskly. Europhen gr. 10, instead of the iodoform and 
creolin, is a good substitute, and nearly free from smell. 

When operative measures are refused by the patient, or for 
other reasons they may not be desirable, caustics find a place. 
Those which have a selective action on the diseased tissue are 



794 DISEASES OF THE SKIN. 

preferable. They are arsenic, salicylic and pyrogallic acids, but 
their use is diminishing in favor of the light, and other treat- 
ments less disagreeable and painful. 

Arsenical Paste (Hebra), (Caustics, F. i). — This is spread 
upon linen, and applied evenly in strips to the affected part; 
a pad of lint is placed over it, bound on firmly, and allowed to 
remain for twenty-four hours; the part is then cleansed and the 
paste reapplied for another day, and again renewed unless there 
is already ulceration, when one or two applications may be suf- 
ficient. To avoid any danger of arsenical absorption only a lim- 
ited area should be treated, say three or four square inches 
at the most, though it is used more freely in Vienna. The great 
advantage of this treatment is that it picks out and utterly 
destroys the diseased tissue, while leaving the healthy tissue 
untouched, and the islands of healthy tissue thus left much 
facilitate the healing and diminish the scar. The disadvantages 
are, that the pain is very severe after the second day, and there 
is great swelling and edema in the neighborhood. These, 
however, soon subside after the removal of the paste. Its use 
is much restricted in favor of other applications. 

Salicylic Acid, as an ointment in the proportion of 3j to §j, 
was first suggested to me by a Mr. Marshall,* and I used it 
with success, and subsequently Unna brought it into notice, and 
introduced plasters (see Formulae) made by Beiersdorf of Ham- 
burg, with 30 and 50 grams of the acid to the meter, and for 
lupus 40 grams of creasote were subsequently added to dimin- 
ish the pain. In these plasters the active ingredients are formed 
into a magma with oleate of alumina, and spread on a gutta- 
percha sheet backed with muslin. It acts far more efficiently 
thus made than when incorporated with the plaster basis in the 
ordinary way, such plasters being almost useless. It is most 
efficacious when applied to raw surfaces, when the disease is 
not very deep-seated, bound firmly on, and renewed once, or 
if there is much exudation twice, daily. A good, smooth cica- 
trix usually results, but the treatment is tedious and painful. 
An even better mode of using it is that of Treves, to add as 
much salicylic acid to glycerin as will make a paste, applied on 
lint. The pain does not last more than a few minutes, but there 
is no objection to adding creasote or carbolic acid (3ss to the 
* Brit. Med. Jour., June 25, 1884. 



LUPUS VULGARIS. 



795 



5J), or, still better, painting on a twenty per cent, solution of 
cocain before applying it. 

Pyro gallic Acid has gained favor of late years in the treat- 
ment of lupus. Besnier brushes on a saturated solution of the 
acid in ether, and then covers it with traumaticin, repeating 
the treatment until all lupus points have disappeared. It acts 
by exciting suppurative dermatitis. Schwimmer also advo- 
cated its use after cleansing the part with vaselin, applying a 
ten per cent, ointment two or three times daily for a week, and 
then putting empl. hydrargyri on the raw surface, repeating 
the process until no more nodules appear. It is not very pain- 
ful as a rule, and is said, like arsenic, to pick out the diseased 
tissue. I have used it with moderate success.* Brocq finds 
the combination of pyrogallic and salicylic acids in ten per 
cent, collodion the most efficacious method of using these sub- 
stances. 

Lactic Acid has been used in the form of the pure acid of a 
syrupy consistence. It is not of much use where the skin is 
sound, unless scarification or scraping precedes its application. 
It should not be kept on too long, or deep scarring may ensue. 
It is most useful for lupus of mucous membranes, and cocain, 
painted on before applying the acid, prevents pain. A twenty 
per cent, solution is often strong enough for the mouth. 

White of Harvard acts on the bacillary theory, and applies 
a solution of bichlorid of mercury, one or two grains to the 
ounce, and says a cure is effected in a few months; an ointment 
of the same strength may be used continuously. Doutrelepont 
indorses White's opinion, using a solution of I in iooo under 
gutta-percha tissue, and both Auspitz and he have injected a 
one per cent, solution into the interstitial tissue in hypertrophic 
lupus of the lip, etc. 

Permanganate of Potash is another drug applicable in certain 
cases, on the method of Schultz of Kreuznach. He paints on 
daily, or every other day, a ten per cent, solution of perman- 
ganate of potash, until a thin, black crust is formed; the nod- 

* It should not, however, be used for a very large surface at a time, as 
dangerous symptoms from absorption have arisen when it has been em- 
ployed over a large area for psoriasis, and occasionally it acts with unex- 
pected energy, and gangrene even has followed too prolonged an appli- 
cation. 



796 DISEASES OF THE SKIN. 

ules are softened, and can be wiped away with cotton wool. 
The treatment requires six or eight weeks. It is adapted to 
superficial and recent cases. Butte uses compresses soaked in 
a two per cent, solution, and Hallopeau has used it also with 
good effect and recommends it in ulcerated and vegetating 
patches, but it is no good in non-ulcerating lesions. Spraying 
with hydrogen peroxid is also useful for ulcerating patches. 

Other caustics, such as the Vienna paste of caustic potash 
and unslaked lime, chlorid of zinc paste and the solid stick of 
nitrate of silver for plowing up the diseased tissue, are given 
up in favor of less barbarous agents, as they are very painful 
for hours, and the first two are non-selective in their action. 

Although these are not a tithe of the measures that have 
been recommended from time to time for this obstinate affec- 
tion, they are those which in my opinion are the most effica- 
cious, and while no one treatment is the best for all cases, the 
methods I use most, apart from the light treatment, are ex- 
cision or erasion on the mixed method, the acid nitrate of mer- 
cury applied with a piece of wool, and salicylic acid ointment, 
paste, or plaster. 

Thus in an ordinary case of lupus, if I had a free hand, unless 
time and money were no object, when Finsen or Rontgen rays 
would be tried, I should operate at once if the patient were in 
good health, as he often is. But if his circumstances did not 
permit it, or it was not deemed judicious to suggest any 
operative measures before his mind was prepared for it, one of 
the palliative measures described or a salicylic acid preparation 
might be used for a time. If the operation were erasion, it 
should be followed immediately by the free application of car- 
bolic acid or linimentum iodi to the wound, and the subsequent 
administration of thyroid extract for a long period, or tuber- 
culin injections before the wound has healed. If the mucous 
membrane of the mouth is involved I should attack it with the 
galvano-cautery or lactic acid. If there were any thickening of 
the scar after healing, repeated scarification followed by the 
application of mercurial plaster would improve it, or thio- 
sinamin injections might be tried, and Finsen light is also of use 
in thickened scars. 

Recurrent nodules would be bored out with a match-end 
clipped in the fuming acid nitrate of mercury, or with 



LUPUS VERRUCOSUS. 



797 



nitrate of silver crayon. Unna prefers the liquor antimonii 
chloridi, and leaves the match-end in for forty-eight hours. 
If the skin over them were hard, Vidal's knife rotated or 
Morris' screw might precede the caustic; or a hard wood 
German toothpick is a very good substitute, and this could 
be dipped in the acid. An ulcerating lupus, spreading rap- 
idly, is best treated by deeply scarifying the border three or 
four times, and rubbing in iodoform directly after each scari- 
fication. Possibly the Rontgen rays would have a good effect. 
In a small number of cases, more or less acutely inflamma- 
tory, all strong measures seem rather to aggravate than cure, 
and milder applications, at all events for some time, answer 
best. Compresses should be bound on, wet with one of the fol- 
lowing lotions: lead lotion Tl^x to Tllxxx to §j, perchlorid of 
mercury I in 2000, boric acid in saturated solution, chlorate 
of potash 5 or 10 grains to the 5j> chloral gr. 5 to the 5J, or weak 
Condy's fluid (red). Calamin lotion is another good applica- 
tion, applied three or four times a day and allowed to dry. 
When the acutely inflammatory symptoms have subsided by 
these means, more radical treatment may be proceeded with. 



LUPUS VERRUCOSUS.* 

Synonyms. — Tuberculosis verrucosa cutis; Verruca necrogenica; 
L. sclereux (Vidal). 

Definition. — A form of tuberculosis of the skin in which there 
is warty development on an infiltrated but not nodular base. 

Although not going so far as McCall Anderson, who con- 
siders L. verrucosus as separate an affection from L. vulgaris 
as is L. erythematosus, the clinical differences from L. vul- 
garis are so considerable that it conduces to clearness of con- 
ception to consider them separately. Pathologically the num- 
ber of tubercle bacilli present is greater than in L. vulgaris, and 
they are proportionately easier to find. 

It is rarer than L. vulgaris, and is the form of disease usu- 
ally assumed when tubercle is accidentally inoculated in the 
skin. Tuberculosis verrucosa cutis of Riehl and Paltauf compre- 

* Author's Atlas, Plates LXIIL, Fig. 4, and LXVIII. Figs. 2 and 3. 



798 DISEASES OF THE SKIN. 

hends the cases of L. verrucosus inoculated from animals in 
butchers, etc., while verruca nccrogcnica represents the anatomi- 
cally identical local tuberculosis that is sometimes produced on 
the hands of those who make post-mortem examinations. 

Clinically the lesion is a slightly raised, infiltrated, and red- 
dened plaque, forming the base on which there is a firmly ad- 
herent warty crusting. This crusting may be fairly uniform 
or much broken up into craggy masses, depending on the de- 
gree of enlargement of the subjacent papillary growth. The 
crusting varies in superficial extent, and may in very indolent 
cases cover the entire lesion and be the only feature visible, as 
if it were merely a diffuse wart, or, as more frequently happens, 
the inflammatory-looking base extends to a greater or less 
extent beyond the warty covering. There is a complete absence 
of the characteristic soft, reddish-brown nodules of L. vulgaris, 
the lesion being very firm to trie touch. It is very liable to 
inflame from time to time, and pus may then be squeezed out 
between the sulci of the horny crust, giving a relief which the 
patient often finds out for himself. It tends to slowly enlarge 
peripherally, and may persist for a great many years, though 
it is said to be more liable to give rise to pulmonary or other 
visceral tuberculosis than other forms of lupus. It attacks the 
limbs, especially the hands and feet, less frequently the face, 
and very rarely the trunk. There is generally only a single 
lesion, but it is not uncommon for it to be multiple, and I have 
seen fifty lesions on the limbs of a boy of ten, and twenty in 
a child of three; in fact, it is the most common form of multiple 
lupus, and the one in which the lesions most frequently appear 
simultaneously or nearly so. Some of these multiple cases 
where the warty character is only slightly developed may be 
mistaken for psoriasis, but there are no scaly crusts, and what 
there are adhere, and in fact, send processes downwards which 
make it very difficult to pick them off. 

In exceptional cases it ceases to enlarge, involution sets in 
from the center outwards, and ultimately produces a spontane- 
ous cure, but not without leaving a scar. In a few cases it 
occurs in a band or streak along the limb.* 

* Hutchinson's smaller Atlas, Plate CXXIX. Plate XIV. illustrates a 
similar distribution, but with different clinical features. See Lupus Mar- 
ginatus. 



LUPUS VERRUCOSUS. 799 

Etiology. — It generally commences in early life, and a febrile 
illness, especially measles, is a frequent antecedent of the mul- 
tiple cases. The probable explanation is that the toxin of the 
exanthem leads to the softening of a tuberculous glands, and 
the liberated bacilli are sent broadcast over the body, but that 
does not explain the concentration of the lesion in the limbs. 
The single lesions probably arise from direct inoculation. 

The so-called tuberculosis verrucosa cutis is most frequently 
seen in butchers, cooks, coachmen, and others who have to do 
with animals dead or alive ; and Fabry * has shown that it is also 
very common in miners, who frequently get slight abrasions on 
their hands and inoculate these from their own nose and 
mouth. The verruca necrogenica is seen chiefly in post-mortem 
porters, pathologists, doctors, and others who handle dead 
bodies, and both these forms affect chiefly the knuckles, inter- 
digital folds, and occasionally other parts of the hands and 
forearms. A good example occurred on the knuckles of a post- 
mortem porter at the East London Hospital for Children, and 
is depicted in Plate LXVIII., Fig. 3, of my Atlas. 

When first seen by me it had been present five years. Soon 
after he began post-mortem work it started on the first knuckle 
of the left hand, where he had knocked off a piece of skin. It 
began as a red, slightly raised, flat papule, on which there was 
no pustule until some time afterwards. The pustule dried into 
a scab, which eventually fell off, leaving the surface slightly 
irregular. The papillae became gradually more prominent, and 
the lesion spread at the periphery, but two or three years 
elapsed before it got quite horny. Meanwhile the disease had 
started at two other foci on the third and fourth knuckles, and, 
progressing at the rate of about half an inch a year, reached 
nearly all across the hand, where it formed an irregular, flat, 
warty mass, raised up about a quarter of an inch, with red, 
slightly raised, sinuous border and sloping edges. On picking 
off part of the horny covering, the red, slightly moist, hyper- 
trophied papillae came into view; and at times the patch itched 
and felt hot, and then, on lateral pressure, a little pus escaped 
between the papillae and gave him relief; otherwise it gave him 
no trouble unless he knocked it. 

* " On the Occurrence of Tuberculosis Verrucosa Cutis in Coal Miners," 
by J. Fabry, Archiv f. Derm., vol. li. (1900), p. 69. 



8oo 



DISEASES OF THE SKIN, 



Pathology. — The lesion is acknowledged to be the result of 
the irritative presence of tubercle bacilli in the skin, and they 
are present in greater numbers than in L. vulgaris, while they 
are not so numerous as in the acute tuberculous ulcer. The 




Fig. 46. — Lupus verrucosus from the back of the thumb. 

a, enlarged papillae ; b, down-growing interpapillary processes ; c, plasma 
cells almost limited to the papillary layer ; d, coil glands. There is 
considerable increase of the horny layers. Tubercle bacilli were 
present in moderate numbers. X 50. 

alliance of the different forms of tuberculosis of the skin is 
shown by the occasional association of L. verrucosus and L. 
vulgaris and scrofulodermia in the same individual. E. 
Knickenberg * collected a series of cases at the Bonn clinic. 

Anatomy. — Riehl and Paltauf f investigated the histology of cases in- 
oculated from animals, and described it as a tuberculosis of the skin, 
intermediate between lupus and tuberculous ulceration. In the upper 

* " Ueber Tuberculosis verrucosa cutis," Archiv f. Derm. u. Syph., vol. 
xxvi. (1894), p. 405. Good abs. An?iales, vol. vi. (1895), p. 163. See also 
Rosenthal in Archiv, vol. xlviii. (1898), p. 151. Abs. in Annates, vol. x. 
(1898), p. 510. 

f Viertelj. f. Derm. u. Syph., 1886, Heft i. p. 19, with colored plates 
of histology. 



LUPUS VERRUCOSUS. 8oi 

part the structure is much the same as in the papillary growths of ich- 
thyosis hystrix, while in the papillary vascular layer, besides foci of in- 
flammation, there were sometimes veritable miliary abscesses, the source 
of the pus occasionally observed in the course of the affection. There 
were also caseating nodules, with the structure of tubercles, containing 
giant and epithelial cells within which were bacilli, with the staining 
reaction of tubercle bacilli, and a few were also found free in the granu- 
lating tissue. These bacilli were more numerous than in lupus tissue, 
but by no means abundant, four or five in a nodule at the most ; cocci 
were also present in the inflammatory tissue. These authors also found 
the same changes in " Verruca necrogenica"; and Unna* found that L. 
verrucosus was anatomically as well as clinically identical with these 
lesions. Fig. 46 shows a lesion I examined. 

Treatment. — If the lesions are multiple, scraping with a sharp 
spoon and the subsequent application of pure carbolic acid is 
the best plan, but for a single lesion less severe measures are 
effectual. The horny covering is first to be got rid of by apply- 
ing repeatedly, for some days at a time, the strongest salicylic 
acid plaster of Unna, and this alone will get rid of a good deal 
of growth; the rest is destroyed with the fuming acid nitrate 
of mercury, applied with a piece of wood. The acid should be 
applied to only a small portion of the growth at a time, as it is 
in some cases very painful for some hours. The Atlas case, 
one of the most extensive I have seen, was quite cured by these 
means. 

Lupus Marginatus, Hilliard's Lupus. Under these names 
Hutchinson f has described a rare form of disease of which he 
has seen four cases. In three of the four the disease began 
on the hand and traveled in a line rather quickly up the ex- 
tremity to the shoulder. The initial patch was the largeat and 
suggested local inoculation. One woman was past forty at the 
onset; the others began in childhood. There was but a scanty 
history of tuberculosis in the patient and family. The majority 
of the component patches were discrete and oval, or crescentic 
in a narrow line on the forearm and arm. In the type case the 
patch over the ball of the little finger was rough and thickened 
and raised a quarter of an inch above the level, not ulcerated, 
but with an adherent scaly crust dipping into minute depres- 

* Unna's Histology. 

f Plates XIII. and XIV. of Hutchinson's smaller Atlas, and four cases 
-are recorded in a lecture, Polyclinic Journal, vol. ii. (1900), p. 104. 

5i 



8o 2 DISEASES OF THE SKIN. 

sions on the surface, thus resembling L. verrucosus. On Mil- 
liard's face there were numerous patches irregularly scattered 
over the lower part of the face and only a few on the fore- 
head. They formed circles, crescents, and gyrate patches with 
delicately papular or nodular borders and a pale, thin, cica- 
tricial area. The patches on his arm partook more or less of 
the characters of the face and hand patches, but in some places, 
especially on the hand, there were narrow lines of little nodules 
of cornlike structure. 

There is no proof that the disease is tuberculous; in fact, the 
pathology is unknown. The disease persisted for a number of 
years, not altering materially after the first year. The only 
availing treatment was to destroy the lesion, which Hutchin- 
son did by attacking the border with the actual cautery; one 
case was treated with potassa fusa successfully. 



MILIARY TUBERCULOSIS OF THE SKIN. 

This may occur in the form of nodules or ulcers, the latter 
being formed by the breaking down of aggregated nodules. 
It is a rare affection, and generally an acute manifestation, 
analogous to visceral miliary tuberculosis, with which it agrees 
in structure and bacteriology. The acute tuberculous ulcer * 
round mucous orifices has long been recognized, but Kaposi,f 
in an analysis of twenty-two personal cases, has brought the 
fact into prominence that the affection may also be seen as 
miliary nodules in the skin, sometimes isolated and scattered 
throughout their course, but more frequently aggregated into 
plaques, generally confined to one region, most commonly the 
face (nose, cheeks, lips, and chin) and the ears, less frequently 
the buttocks, perianal region, elbow, forearm, etc. 

In a man, set. twenty-one, attending U. C. H. with numerous 
scrofulodermia lesions on the upper and lower limbs, the right 
leg became suddenly swollen and painful; he felt ill and was 
in bed two days. When seen a few days later there were a 
large number of pin's-head to hemp-seed-size nodules scat- 

* Neumann's Atlas, Plate L., gives a good representation of acute 
ulceration of the nostrils, 
f Kaposi, Arch.f. Derm. u. Syph., vol. xliii. (1898), p. 373. 



MILIARY TUBERCULOSIS OF THE SKIN. 803 

tered over the leg, which underwent very little change beyond 
slight enlargement in the course of a year. 

In one-third of Kaposi's cases the skin alone was affected; 
in one-third the adjoining mucous membranes were also in- 
volved, the mouth, tongue, palate or nose, and less often the 
vulva, vagina, or anus. The aggregated nodules may coalesce 
into a flattened infiltration, and break down into characteristic, 
very superficial, painful ulcers,* with finely denticulate borders, 
which, as well as the base, are pale red and covered with sero- 
viscous secretion. The borders also present, at once or ulti- 
mately, minute nodules, isolated or in several rows, which 
ulcerate and join on to the main ulcer, and thus produce 
the finely dentate borders. They are not present at all 
periods. 

The ulcers of mucous membranes have similar characters, 
rounded, dentate borders, with a grayish coating over the base 
and very often miliary nodules round them. One-third of Ka- 
posi's cases developed acutely in three or four weeks, the others 
at various periods up to three or four years. Most cases are 
associated with tuberculosis of the respiratory organs; less fre- 
quently other viscera are affected, but it is not specially asso- 
ciated with acute miliary tuberculosis of the viscera nor neces- 
sarily towards the end of the internal disease, for they some- 
times heal spontaneously, and more frequently if treated with 
local antiseptics and well-directed general treatment. 

Iodoform would probably be the best application, and then 
boric acid ointment. Well-marked cases involving the skin, 
both developing acutely after measles, are recorded by Leich- 
tenstern f and Pellagatti.J In the former's case, a child of 
four, there was acute miliary tuberculosis of the viscera, and 
on the face, trunk, and limbs, poppy seed to hemp seed, firm 
red, acuminate papules; some developed a vesicle, others a pus- 
tule on the apex of the papule, and the majority in from one 
to two weeks involuted with a small scale or crust; stained sec- 
tions showed numerous tubercle bacilli. 

* They are sometimes large ; Hallopeau had a case of perianal ulcer, 
5 in. X 3 in. 

f Munch, med. Wochensch., No. 1 (1897), p. 1. Full abs.in Brit. Jour. 
Derm., vol. ix. (1897), p. 247. 

JPellagatti, " Giorn. Ital. d. Mai. Ven. e d. Pelle," 1898, p. 704. 



8o4 DISEASES OF THE SKIN, 

Chronic miliary and large nodules isolated or aggregated in 
the skin are met with from time to time, such as Dale James' 
case,* where there were two or three groups on the face, one 
of them on the nose; and Du Castel's,f where they were more 
numerous, and had been present two years in a child of five, 
immediately following measles. In neither of these were there 
visceral lesions. 

Ulcers J of slower development with abundant bacilli also 
occur, and not necessarily with visceral tuberculosis. 

In Jessner's case,§ in a girl of fifteen, reddish-brown, soft nod- 
ules had been developing for six years on the nose, head, back, 
and extremities. They were from one to five lines in diameter, 
the largest hemispherical, the smaller ones conical, some iso- 
lated, some grouped, some smooth, others frambesiform, but 
not moist; others were slightly scaly, but in most the surface 
was undisturbed and were all alike. The microscope and inoc- 
ulation into guinea-pigs and rabbits showed them to be tubercu- 
lous granulomata. 

Liddell's case || was in flatly convex, smooth, firm, deep red, 
or violaceous half-inch patches on face, arms, and feet. Their 
tuberculous nature was first revealed by the microscope, which 
showed them to be made up of nodules of a tuberculous 
structure. 



ACUTE TUBERCULOUS ULCER OF THE SKIN. 

Symptoms. — This is a variant of miliary tuberculosis, and an 
extremely rare affection, Chiari having found it only six times 
in 7000 post-mortems, of which about sixty per cent, had died 
of tuberculosis. It is almost limited to the lips and other 
neighborhoods where the mucous membranes join the skin, viz., 
the nose, the anus, vulva, and glans penis, but in one case it 
was behind the ear. The lesions consist of one or more dis- 

* Dale James, Sheffield Med. Jour., October, 1892. Abs. Brit. Jour. 
Derm., vol. v. (1892), p. 58. 

f Du Castel, Annates de Derm, et de Syph., vol. ix. (1898), p. 729. 

% Author's Atlas, Plate LXII.. Fig. 3. An ulcer at inner canthus in 
connection with the lacrymal duct. 

§ Internat. Atlas, Fasciculus xiii., Plate XXXIX. 

|| Brit. Jour. Derm., vol. xii. (1900), p. 319. Lupus circumscriptus 
(nodularis). 



ACUTE TUBERCULOUS ULCER OF THE SKIN. 805 

crete, shallow, not painful ulcers, which form apparently 
spontaneously,* have an irregular, eroded, .moderately infil- 
trated edge, and, when the crusts which soon cover them are 
removed, show a reddish-yellow, granular surface, with a thin 
scanty secretion. They never heal, spread slowly but continu- 
ously, and may coalesce with neighboring ulcers, becoming, as 
in Jarisch's case, seripiginous ; they may thus extend over an 
area of one or two square inches, but as a rule are small; when 
on mucous membranes, yellow miliary papules exist near them. 
Since they are usually only part of an extensive infection, espe- 
cially of the lungs and the mucous membrane of the respiratory 
and digestive tracts, they have a comparatively rapid down- 
ward course of a few months at the most. In a case of Ka- 
posi's the skin lesions were thought to be primary, tubercu- 
losis elsewhere being limited to the intestine. f 

Diagnosis. — Their nature may be suggested by the evidence 
of tuberculosis elsewhere, especially when there are ulcers on 
the oral mucous membrane or tongue. In the absence of signs 
of general tuberculosis, the diagnosis is often only made post- 
mortem, when the microscope shows, in addition to the uniform 
leukocytic or lymphoid infiltration at the base and border of the 
ulcer, close by, or even away from the original seat of disease, 
true miliary tubercles, consisting of lymphoid, epithelioid, and 
giant cells, often showing signs of commencing caseation. The 
best local treatment would probably be iodoform. 

Tuberculous ulcers may be acute or chronic, primary or sec- 
ondary. They are acute and primary in miliary tuberculosis, 
chronic and secondary in lupus vulgaris and scrofulodermia. 
These are often complicated with papillomatous development, 
or, more correctly, papillary growth, and are then often called 
lupus papillomatosus. Doutrelepont J also describes ulcers re- 

* Viertelj. f. Derm. u. Sypk., 1879, p. 269. A very good representation 
is in Plate L. of Neumann's Atlas. Plate LXII., Fig. 3, of the Author's 
Atlas shows tubercular ulcer of slower development in connection with 
the lacrymal duct. 

f In a case of phthisis reported by Vidal, hard bean-sized nodes pre- 
ceded the ulcers on the breast, face, shoulder, and arm; these " tuber- 
culomata " softened and discharged a whitish tough mass. Nobl, Wi'en. 
med. Presse, No. 31, 1900, p. 106, summarizes the cases and condition to 
date. 

% Archiv f. Derm. u. Syph. (1896), p. 278. 



806 DISEASES OF THE SKIN. 

sembling varicosed ulcers, and others like a phagedenic 
chancre. According to Hallopeau and Wickham, tubercle 
bacilli may be pyogenic through their toxins, and produce 
pustulo-ulcerations, such as were formerly described as im- 
petigo rodens, and the pus will produce tuberculosis in guinea- 
pigs, although no bacilli can be found in the original pus. This 
lends some support to the theory of some French authors of 
glceic tuberculosis with absence of separate bacilli. Serpiginous 
ulceration resembling the serpiginous nodular syphilid may be 
occasionally met with. Brownish-red infiltrated patches or 
nodules break down into centrifugally spreading ulcers with a 
gray or reddish-yellow floor, and more or less cicatrization 
intermingled. The disease may affect a large or small area, and 
secondary lesions may form, and even visceral tuberculosis 
ensue. 



SCROFULODERMIA.* 

Deriv. — Scrofa, a sow. 

Symptoms. — This term includes the various forms of sup- 
purating dermatitis which attack strumous persons, who, al- 
most always at the same time, present some of the other mani- 
festations of this condition, such as enlarged, caseating, and 
suppurating glands, conjunctivitis, or the scars of keratitis, 
blepharitis, rhinorrhea, or otorrhea, joint or bone disease, etc., 
and probably the characteristic physique. 

The most common origin for the lesion is in the skin over 
caseating and softening lymphatic glands, which implicate the 
tissue over it, so that the skin becomes red, flabby, under- 
mined, and even riddled with sinuses, which have been, or are 
in communication with the remains of the gland below. Ul- 
cerations starting from this inflamed skin may slowly spread 
over the face and neck, which are the commonest positions for 
such lesions. In other cases lupus vulgaris develops round a 
sinus constituting one form of scrofulous lupus. They may 
also occur independently of the glands, beginning as nodules 
(Scrofulo-gummata) in the subcutaneous tissue, which enlarge 
to hazel- or walnut-sized tumors, and implicate the skin over 
* Author's Atlas, Plates LXII., Fig. 2, and LXVIII., Fig. i. 



SCROFULODERMA. 807 

them; this becomes red, but not very tender, while the tumors, 
which are almost painless, soon soften with obvious fluctua- 
tion. Even then they may become absorbed and disappear, 
leaving only a red spot to mark their site. Or the tumor may 
be evacuated spontaneously or by incision, and either heal up 
slowly, or form a spreading ulcer. The scrofulo-gummata may 
occur in the course of the lymphatics of a limb,* as in cases 
described by Lailler, Besnier, and Hallopeau. 

The strumous ulcer varies; sometimes it has thin, red, under- 
mined edges, with irregular base, and flabby, thin, pus-covered 
granulations; or there may be only a flat ulcer, with sharply 
cut edges slowly spreading, but seldom healing spontaneously; 
such ulcers may be seen sometimes at advanced age in people 
who bear the scars and features of a strumous childhood, and 
are liable to develop into rodent ulcer or epithelioma. These 
ulcers of senile struma f often take on a papillary hypertrophy, 
and may form the so-called lupus papillomatosus,J which are, 
as I have previously stated, referable to scrofulodermia rather 
than to true lupus. 

Sometimes in ulcers of moderate size the pus dries in en- 
larging layers as the ulcer spreads, and the limpet-shell appear- 
ance of rupia is imperfectly produced, for the process being 
slower the crust is not so well formed as in the syphilitic lesion, 
but it used to be designated " scrofulous rupia." 

When the soft tumors, above described, occur on the limbs — 
a frequent position — the bones are also sometimes implicated, 
especially those of the fingers. In such cases they may form 
a tumor embracing the whole segment, and the bone often 
becomes carious (strumous dactylitis). This results in consid- 
erable deformity, and is the lupus mutilans § of some authors. 

In some of these cases there is papillary hypertrophy and 

* There is a model in the Museum of the College of Surgeons of this 
condition, showing suppurating and other nodules extending up the arm 
from a lesion of the thumb. No. 170a, Derm, series; and Plate XXXVI., 
St. Louis Atlas. 

f Paget, " Clin. Essays," "Senile Scrofula"; Howard Marsh, "Senile 
Tuberculosis," Lancet, April 16, 1892; Colcott Fox, four cases, Brit. Jour. 
Derm., vol. iv. (1892), p. 160; also Travers Smith, ibid. 

% Author's Atlas, Plate LXIII., Fig. 3. 

§ Plate LXIL, Fig. 2, Author's Atlas. Plate LXXL, Hutchinson's 
smaller Atlas. 



808 DISEASES OF THE SKIN. 

fungating growths, and the skin is of a livid red, pierced by 
numerous sinuses. 

Strumous people are very liable to recurrent lymphangitic 
attacks at short intervals, often very like erysipelas. When this 
occurs in the lower limbs — its most frequent seat — a chronic 
lymphatic edema results, which leads to the development oi 
elephantiasis of the limb, often with considerable papillary 
hypertrophy. It is also not uncommon in the face, and leads 
to permanent swelling of the features, especially the nose, 
cheeks, and upper lip. There may or may not be true lupus 
associated with it in the earlier stage; if there is, the condition 
called by older authors " lupus hypertrophicus " is produced. 
Under the name of primary tuberculosis of the skin Dr. Hebb 
read a paper on a case of this kind at the Medico-Chirurgical 
Society in March, 1886,* in which the patient, aet. eighteen, had 
died with what was considered to be elephantiasis Arabum of 
the leg, and the skin showed microscopically, in addition to the 
usual appearances of elephantiasis, aggregations of large and 
small lymphoid cells with numerous giant cells interspersed, 
and in the lymphatics and among the aggregations of lymphoid 
cells abundance of small bacilli, staining like those of tubercle. 

Tuberculous Tumors. Doutrelepont described a case of tu- 
berculosis of the skin which suggested a mycosis fungoides, or 
a sarcoma of the skin. The patient was a girl of six, who had 
had good health up to two years old, when she had measles, 
and the other disease began during the eruptive period, com- 
mencing as a tumor of the upper lip, followed by twenty-eight 
similar tumors on the chin, neck, trunk, and limbs. They were 
round, sharply denned, and of variable size. The smallest con- 
sisted of a uniform, circumscribed, smooth infiltration, which 
projected but slightly, while the largest projected considerably 
above the surface, and were furrowed and covered with crusts 
and scales, but all except those on the hands were smooth, 
while the hand-growths showed on removing the crusts and 
scales an ill-developed papillomatous structure. There were 
no ulcerations, cicatrices, or traces of scars on or near the 
tumors. They were movable with the skin. There was general 
slight enlargement of the lymphatic glands. Nothing in the 
* Brit. Med. Jour.., March 27, 1886. 



SCROFULODERMA. 809 

family history, but injections with the first tuberculin showed 
local reaction, and the histology and inoculation experiments 
confirmed the inference that the neoplasms were tuberculous.* 

Hallopeau quotes Riehl's, and Wickham and Gaston's cases f 
to show that similar tumors may aggregate and ulcerate. 

Eruptions which might be included under the term tubercu- 
lids sometimes precede the gummatous lesions. Morris J 
showed a case at the Dermatological Society of a boy with 
a strong family history of tuberculosis, in whom six months 
previously there had been a transitory eruption of pimples, fol- 
lowed by the development of nodules of variable size and shape 
from a lentil to a nux vomica seed, better felt than seen, though 
over some of them the skin was bluish-red. They were firm, 
movable, and tender, and scattered over the limbs, especially 
the legs. Hallopeau § had a case which began with papules like 
lichen scrofulosorum, then became pustules, which coalesced 
into patches, some of them over two inches in diameter. The 
center became depressed and ulcerated, while the periphery 
indurated and one part became bullous. 

Pathology. — It has long been assumed that scrofulodermia is 
a form of tuberculosis of the skin, and tubercle bacilli have 
from time to time been found in it; but as far back as 1884 
Arloing || found that scrofulous glands did not produce visceral 
lesions in the rabbit, while pulmonary tuberculosis did do so. 
He made further experiments which confirmed him in the view 
that tuberculosis and scrofula were not identical. More re- 
cently (1897), Ritter j[ set himself the task of answering the 
question, " Does scrofulous tissue contain tubercle bacilli at 
the outset?" and his answer is in the negative, although he 
admits that in advanced cases tubercle bacilli are often found. 
His conclusions are: That the processes of tuberculosis and 
scrofulosis are not identical, but that the presence of scrofulosis 
affords a favorable soil for the invasion of the tubercle bacillus, 

* Archivf. Derm. u. Syph., vol. xxix. (1894), p. 211. Abs. in Annales, 
vol. vi. (1895). p. 434. 

\ Loc. cit., Derm. Cong. Trans., p. 406. 

% Brit. Jour. Derm., vol. ix. (1897), p. 331. 

§ Annates de Derm, et de Syph., vol. vi. (1896), p. 1093. 

I Ads. Brit. Med. Jour , October 16, 1886, " Annotation." 

1 Ritter, Allg. med. cent. Ztg. (1896), lxvi., p. 654. Abs. in Clin. Jour., 
July 27, 1898, p. 279. 



8io DISEASES OF THE SKIN. 

and, as is well known clinically, a slow intermingling may 
occur, and that there exists a great affinity between the two 
processes. 

Diagnosis. — Scrofulodermatous ulcers and nodules have to be 
distinguished from lupus vulgaris and syphilis. 

In lupus vulgaris, while the other strumous lesions are pres- 
ent, there is an absence of the characteristic lupus nodules, 
destruction, and not infiltration, being the distinguishing feature 
of scrofulodermia. When the two conditions are present to- 
gether * the ulcers are often deep and the crusts thicker, 
greener, and more prominent. 

Although most of the lesions are distinguishable some seem 
to shade off, and the two conditions to be so mixed up together 
sometimes that it is impossible to decide between them; but the 
treatment being on much the same lines in such cases, the exact 
diagnosis is not so important. 

The distinctions from syphilis are the same as those between 
lupus vulgaris and tertiary syphilis. Leloir,f however, claims 
to have proved, both clinically and pathologically, that there 
were mixed conditions in which the lesion was a compound of 
scrofulo-tuberculosis and syphilis — in other words, that there 
was a bona fide syphilitic lupus. His paper has not carried con- 
viction to my mind that this view is correct. 

Treatment. — This should be directed to the general health, 
where possible, by improving the surroundings, e. g., sending 
the patient to live at the seaside, the administration of cod-liver 
oil and iron in full doses, such as 3ss to 5j of the syrup of the 
iodid of iron, with a liberal diet. Thyroid extract, given as in 
lupus vulgaris, should also be tried. 

Locally, unhealthy fungating granulations should be scraped 
away with a sharp spoon and strong carbolic acid applied; 
undermined skin should be snipped off with scissors, sinuses 
laid open, and the ulcers dressed with recently prepared iodid 
of starch paste or iodoform, or the yellow or black wash applied 
under oiled silk. Where operative treatment is undesirable or 
unsuccessful, salicylic and glycerin paste with carbolic acid is 

* Examples of this combination are in Author's Atlas, Plates LXII., 
Fig. i, and LXIIL, Figs, i and 2. 

\Jour. des Mai. Cutan., vol. for 1891, September number, and long 
abstract, Brit. Jour. Derm., vol. iv. (1892), p. 165. 



ERYTHEMA INDURATUM. 811 

very efficacious. Chaulmoogra oil internally, in the form of 
emulsion, in from ten to thirty-minim doses, and externally as 
an ointment one to three, has, where tolerated, an admirably 
good effect. For the multiple cold abscesses, sulphid of calcium 
pills, gr. 1-6 ier die, may be given along with general measures, 
but each abscess should be opened as soon as it is recognized, 
syringed out with carbolic lotion I in 40 and iodoform dressings 
applied. 

ERYTHEMA INDURATUM.* 

Synonym. — Bazin's Disease. 

Definition. — A disease characterized by deep-seated gumraa- 
like nodules, chiefly of the legs, of slow course, and tending to 
break down into ulcers. 

Erythema induratum is a rare affection in England, but was 
described by Bazin as not uncommon in France under the name 
of " Erytheme indure des scrofuleux." His description was, 
however, overlooked or misunderstood for some years even in 
France, and it is only in recent years that it has again attracted 
attention. It has no relationship to E. nodosum or other form 
of E. multiforme, although it bears some resemblance to the 
former. Bazin did not describe the ulceration, which is now 
recognized as a common feature. 

Symptoms. — The disease attacks the calf, or immediately be- 
low it, more frequently than the front of the legs, and has often 
a single plaque, but there may be many. Bazin speaks of it as 
acute in its onset, bright red at first, but gradually assuming 
a violet hue, and it is either in a diffuse, ill-defined patch or in 
nodules. As I have seen it, the nodules may be either super- 
ficial or deep in the cutis, the latter often showing no alteration 
on the surface, and only perceptible to the touch as they be- 
come more superficial. They are bright red at first, fading to 
a more livid hue; the borders are ill-defined; and the lesions, 
which may be either in nodules or plaques, are from a quarter 

*Colcott Fox, Brit. Jour. Derm., vol. v. (1893), p. 225, colored plate, 
gives history and literature to date; and in Trans, of Thirtee?ith 
Tnternat. Cong., Derm. Section, at Paris. 1900, p. 115 and p. 113, Boeck, 
Colcott Fox, and others discuss its relationship to tuberculosis. 



812 DISEASES OF THE SKIN. 

to an inch or more in diameter, always better felt than seen, 
and they may coalesce into large brawny infiltrations in the 
calf, and less frequently in the front of the leg. These indura- 
tions, with or without a slightly livid surface, may either be 
very slowly absorbed, or they may necrose and slough out, leav- 
ing a very indolent ulcer, strongly suggestive of specific origin. 
Strumous girls and young women are most liable to it, but it 
may occur in boys, and I have seen a marked instance in a man 
of thirty-six * of phthisical stock, but not himself consumptive. 
It had been going on from the age of eighteen at intervals, but 
the actual attack I saw was of seven weeks' duration. He had 
nodules and ulcers, the largest of the latter the size of a shilling, 
deep and sloughy. The case of Galloway's mentioned below 
was a man of twenty, and C. T. Dade's case was a man of forty- 
two. I have seen it in a woman over fifty, who had, however, 
suffered from the same thing when a girl. She had in addi- 
tion lupus vulgaris of old standing. Colcott Fox has observed 
small suppurative nodules on the fingers (folliclis) associated 
with this disease in several cases. He and Galloway have also 
noted angio-keratoma in the same subjects as E. induratum, and 
Galloway's case also had folliclis, so too had J. C. Johnston's 
case. Hutchinson says that pustular ophthalmia is a feature 
of the disease, but his experience is not the usual one. 

In a severe case of mine, in a woman, set. thirty-seven, there 
were a few nodules on the upper limbs. Pringle and S. Mac- 
kenzie have also had cases affecting the arms, and Galloway had 
a case affecting all the limbs, shoulders, and ankles. The diag- 
nosis of these cases was not absolutely conclusive. Pain and 
tenderness are usually absent, but may be marked. Edema of 
the legs is not unfrequently present, but whether before or after 
the development of the nodules is doubtful. The cases, how- 
ever, in which there is edema, lividity, and diffuse induration 
from the stagnant circulation belong to a different category. 
The disease runs a very indolent course of months, or even 
years, with a tendency to recurrence. One of Hutchinson's 
cases lasted with intermissions for twenty years. 

Etiology. — It is much more common in females than males, 
and in the second decade of life, and has not yet been noted 
much beyond the fifth. It is most frequent in winter, especially 
*Mr. F. T., Case Book F., p. 286. 



ERYTHEMA INDURATUM. 813 

in those who have cold hands and feet (the chilblain circula- 
tion), and have much standing; hence washerwomen are fre- 
quent victims, especially in countries where they wash out of 
doors. A considerable number have evidence of tuberculosis 
in themselves or their family, but the tide of opinion has ebbed 
and flowed against the original view that it is a scrofulous dis- 
ease, or that it should be reckoned as a tuberculid (see Pathol- 
ogy). Hutchinson considers it the former, Boeck the latter; 
and Hutchinson does not consider scrofula and tubercle identi- 
cal, though often allied. 

Pathology. — The pathology is still not beyond discussion, un- 
less Thibierge's and Fox's experiments are considered to settle 
the question. The most modern view is that it is a tuberculous 
affection, due to the direct presence of bacilli, owing much of 
its characters to a defective circulation, as evidenced by its al- 
most always occurring on the legs, and its greater frequency in 
those who stand much and are exposed to cold, especially in 
winter. 

Anatomy.* — Audry was one of the first to make a histological investi- 
gation, and found spontaneous local edema followed by fatty degenera- 
tion. This was confirmed by Ewing in Dade's case. J. C. Johnston and 
Leredde also found perivascular changes, but none of them found "giant 
cells," or other proof of its tuberculous origin. Thibierge and Bavant, 
however, not only found giant cells, but successfully inoculated a guinea- 
pig and produced fatal tuberculosis in thirty-five days; and Colcott Fox 
and Eyre confirm this, both as regards giant cells and also fatal inocula- 
tion of tuberculosis in a guinea-pig. 

Mantegazzaf examined two cases histologically, and found granulo- 
matous structure and giant cells, but no bacilli, neither by microscope nor 
by guinea-pig inoculation. He rejects the idea of tubercle toxins, and 
thinks that the lesions could only be produced by the bacilli themselves, 
though they be sparse and attenuated. He thinks it should be classed 
with the scrofulodermata, and not with tuberculids. 

Whitfield reconciles these discrepancies by contending that 
there are two distinct affections included under erythema in- 
duratum: one of tuberculous nature, rebellious to treatment, 

* Review by C. Fox, loc. cit., and Brit. Jour. Derm., vol, x. (1900), p. 

389- 

f Full review to date, as well as histology of his two cases, Ann. de 
Derm, et de Syph., vol. ii. (1901), p. 498. Full abs. Brit. Jour. Derm., 
vol. xiii. (1901), p. 438. 



8 14 DISEASES OF THE SKIN. 

coming on exclusively in young girls, and painless unless it has 
ulcerated; the other occurring in middle-aged women, less pain- 
ful, more easy to cure, having nothing to do with tuberculosis, 
and corresponding to the nodular necrotic phlebitis of Philipp- 
son. Audry, Galloway, and some others regard it as a chronic 
and sometimes ulcerative variety of erythema nodosum, but I 
think the clinical appearances and course are opposed to this. 
Neither can Whitfield's contention be considered as more than 
a general truth as regards age and sex, as my own adult male 
was an indisputable case, and there are others like it on 
record. 

Diagnosis. — The prominent features are: its localization to 
the legs, especially the calves; the presence of gumma-like nod- 
ules often ulcerating; its chronic, almost painless course; and 
finally that most of its victims have a feeble circulation and 
come under the term scrofulous. 

It differs from erythema nodosum in the following respects: 
it occurs more on the back than the front of the legs; its char- 
acters are indolent, but it tends to ulcerate; tenderness and 
febrile symptoms are absent; it has a long duration with re- 
lapses; and the number of lesions, although small at first, 
ultimately is large. There are no rheumatic associations, 
but those of tuberculosis and of a feeble circulation are fre- 
quent. 

From gummatous syphilis it differs in its etiology, duration, 
evolution, and finally, if there is still doubt, by its not respond- 
ing to specific treatment; indeed, iodid of potassium often ag- 
gravates it. 

Treatment. — Before ulceration has occurred careful but firm 
bandaging, with moderate exercise, is the right course, and 
Hutchinson says that the application of an ointment of hydrarg. 
bisulphuret gr„ v., adip. benz. 5J, is almost a specific; after 
ulceration prolonged rest with the legs raised is indicated, to- 
gether with tonics and good living, but the course is generally 
very slow. 



LUPUS ERYTHEMATOSUS. 815 



LUPUS ERYTHEMATOSUS.* 

Synonyms. — Seborrhcea congestiva (Hebra); Lupus erythema- 
todes; Lupus superficialis (Parkes and Thompson); Lupus 
sebaceus; Fr., Older authors; Scrofulide erythemateuse; 
Erytheme centrifuge (Biett); Ger., Lupus erythematosus. 

Definition. — A cellular infiltration, producing various-sized, 
red, scaly patches, clinically resembling an inflammation, but 
with a tendency to atrophic scarring. 

L. erythematosus is only half as frequent as L. vulgaris f in 
hospital practice, occurring only in 6.3 per 1000, but in private 
practice it is twice as common, viz., nearly 18 per 1000, against 
9.8 per 1000 L. vulgaris. It was described by Biett, Hebra, 
Parkes, Thompson, Cazenave, etc., under various designations, 
but that of Cazenave has displaced all others. 

Clinically it may be divided into four varieties: 

1. Circumscribed or discoid; 

2. Diffuse or disseminated; 

3. Telangiectic; 

4. Nodular. 

Symptoms. — The circumscribed or discoid is the most com- 
mon form, attacking chiefly the head and face, especially the 
nose, cheeks, and lobes of the ears, often symmetrically. 
While no part of the body can claim absolute exemption, the 
next most frequent seats, in addition to the bridge of the nose, 
cheeks, and ear lobes, are the tip and alae of the nose, the 
orbits, the lips in all parts, the scalp, leading there to perma- 
nent loss of hair, and the back of the fingers and toes. In the 
early stage it usually appears as isolated or grouped small red 
spots, about one-eighth of an inch in diameter, with a yellow- 
ish spot and a small, closely adherent scale, evidently sebaceous 
in the center, and when this scale is removed, it is found to dip 
deeply into the dilated sebaceous gland-duct, in which it forms 

* Literature.— Author's Atlas, Plates LXIV., LXV., LXVL, LXVII. 
Plate XLII. "Syd. Soc. Atl.," Duhring's Plate C, Hebra's Atlas, Plate 
VIII., offer some of the best illustrations of the chief varieties. 

f Bulkley finds it more common than L. vulgaris in America, and Kopp 
in Munich met with thirty-five cases out of eight hundred of all forms of 
skin disease. 



816 DISEASES OF THE SKIN. 

a plug. This is the stage which Hebra first described as sebor- 
rhea congestiva, or primary eruptive spots; these spots slowly 
extend peripherally, and ultimately coalesce into one or more 
reddish patches of varying size, still scaly, and with conspicuous 
yellow sebaceous plugs. These patches often present a dirty 
yellowish-white appearance, rough to the touch from the horny 
plugs in the follicles, while the border of the patch is red, and 
raised above the central portion. This condition is most 
marked on the nose, but is also seen on the malar eminences 
and in the scalp; it is the L. scbaceiis of Hutchinson. When it is 
more uniformly inflammatory, the patch, which is only slightly 
raised above the surface, but has a well-defined border, con- 
tinues to enlarge, undergoes involution in the center, which 
sinks down and ultimately may clear away completely. It then 
leaves only a thin white cicatricial area, with a red raised bor- 
der about one-eighth of an inch thick, which is often still 
studded with horny comedones; or, if the involution be incom- 
plete, it remains slightly reddened, with closely adherent scales. 
Not infrequently the nose and cheek patches enlarge until they 
meet and form one large patch, resembling a butterfly in out- 
line; but the disease is usually of many months' or years' dura- 
tion before it has attained to this size. 

Another mode of commencement is that of well-defined, very 
bright, uniformly red spots, which become raised patches, hot 
to the touch, and slightly desquamating. This erythematous 
aspect is very persistent as a rule, but may, either spontaneously 
or by treatment, clear away without leaving a trace behind; but 
more frequently there is some atrophic scarring. I have also 
seen it as persistent red plaques, like an erythema exudativum, 
the epidermis being unaffected. This last form is very rare, 
and the other erythematous variety is more often seen in the 
disseminated than in the circumscribed form. In these modes 
of commencement the follicles are not primarily affected, as 
in the sebaceous form. In the scalp it also begins in the 
follicles. 

While, as a rule, there is only slight scaliness most marked 
at the border, in others there is a distinct horny, closely ad- 
herent crust covering the whole surface, but with a bright red 
border beyond. When the back of the hands is affected it often 
takes this crusted form, with red borders. In a case of Hallo- 



LUPUS ERYTHEMATOSUS. 817 

peau's,* a man of sixty-one, a warty development occurred, 
something like that of L. verrucosus. 

When the patches coalesce irregular or gyrate patterns are 
produced, but they do not enlarge indefinitely, but after a varia- 
ble time become stationary or involute still further, even the 
borders becoming less red and prominent. Ultimately, in a few 
fortunate cases, nothing may be left except the thin white scars ; 
yet even then recurrence may take place in the scar, and by 
this means, and by the formation of fresh patches, keep up the 
disease for an indefinite time. Spontaneous ulceration is ex- 
ceptional, except in the lobes of the ears and on the scalp. As 
a rule, in this class of case, there is no disturbance in the gen- 
eral health, but complications may occur, such as erysipelas, 
and, indeed, sometimes the lupus appears to date from an at- 
tack of erysipelas. On the other hand, erysipelas may produce 
a very rapid involution of the disease. In the case of a young 
woman with crusted L. erythematosus over almost all the face, 
an attack of erysipelas was followed by the complete disap- 
pearance of the disease over almost all the affected area, except 
a small patch on each cheek, leaving a white thin cicatrix. Un- 
fortunately, the patches that were left slowly spread, until a great 
part was again involved, but it was never over so large an area, 
nor was it so crusted, as before. 

In the diffuse form,* L. disseminatus (Hebra), the patches 
are much more numerous, but each commences in much the 
same way, except that the erythematous mode of onset is more 
frequent than the seborrheic. The patches nearly always begin 
on the face, and, in addition to the positions already enu- 
merated, may form in any and every part of the body, usually 
attacking the limbs before the trunk, so that the eruption by 
coalescence may, in rare instances, become well-nigh universal. 
As a rule, it involves large surfaces, gradually invading one 
place after another, though by no means continuously. 

In this form the disease may be acute, either from the first, 
or successive acute outbreaks may supervene upon what was 
apparently an ordinary chronic and localized condition. The 

* Ann.de Derm, et de Syfth., vol. iii. (1892), p. 206. 

f Kaposi's Hand Atlas, Plates CLXXXIX., CXCV., CXCVI., acute 
bullous febrile type, like persistent erysipelas of the face, CXCVIL, 
CXCVIII. 

52 



818 DISEASES OF THE SKIN. 

initial lesions are covered with crusts instead of scales, and 
when closely aggregated resemble a pustular eczema, the dif- 
ferences being that the elementary component lesions are al- 
ways discernible, the crusts very adherent, and when removed 
reveal the patulous sebaceous openings. These acute cases 
are always accompanied by marked febrile symptoms of an 
irregularly intermittent type, with severe headache and boring 
pains of the bones and joints. Kaposi also describes persistent 
erysipelas-like swellings of the face with typhoid symptoms, a 
temperature of 104 F. with coma, and a mortality of fifty per 
cent. 

In a case under Hallopeau * the eruption, at first only on 
the face, progressively invaded the trunk and limbs. The out- 
breaks of eruption were like a persistent polymorphous ery- 
thema, sometimes with vesicles or bullae, and always preceded 
and accompanied by intense itching. The case was thought to- 
be an early stage of mycosis fungoides, but subsequently the 
diagnosis became clear, some of the patches disappearing, and 
others becoming cicatricial, and with the typical characters of 
L. erythematosus. Besnier records a similar case.f Kaposi 
and Abraham have also had cases with bullae. In a case of my 
own, set. thirty-six, it followed uremic convulsions as a general 
erythema in thumb-nail-sized discs, in which condition I first 
saw her in consultation with Mr. Bailey. She recovered from 
this, the albumin dropping from one-third to a trace, and then 
lupus erythematosus developed on the orbits and cheeks, then 
over the whole scalp, which was denuded of hair and became 
cicatricial. Subsequently it extended to the extremities and 
trunk, but I only saw her once in this stage. The eruption was 
erythematosus for the most part, but in some places scaly and 
crusted. She died about four months from the onset of the 
lupus development, probably from the old kidney disease. J 
This occurrence of albuminuria with widespread disease has 
also been noted by Abraham, Sequeira, and others, and should 
be looked out for in acute cases. 

* Ann. de Derm, et de Sypk., vol. for 1891, p. 389, and abs. Brit. Jour. 
Derm., vol. iv. (1892), p. 123. 

f Besnier, Annates, vol. iii. (1892), p. 455, both of the type of Kaposi in 
Plate CXCVI., above mentioned. 

£ Private notes, H., p. 611. 



LUPUS ERYTHEMATOSUS. 819 

Kaposi describes the following local complications of the 
acute and subacute cases: (1) Sometimes, preceding the develop- 
ment of " the primary eruptive spots," subcutaneous, deeply 
seated, doughy, painful, and tender, nut-sized nodules appear 
while the skin over them is still normal, and disappear when 
" the primary eruptive spots " are fully formed. (2) Nodular, 
edematous, painful, doughy swellings, on which L. erythema- 
tosus spots may or may not subsequently appear, develop on 
the' skin and tissues round the joints of the hands, feet, knees, 
and elbows. (3) Very numerous " hemorrhagic flat blebs," 
from a lentil to a sixpence in size, disseminated or grouped 
round a central bulla, like a herpes iris; if the raised epidermis 
is removed, a hemorrhagic point in the corium is still left, about 
which the eruption spot subsequently develops. (4) Swelling 
of the parotid and lymphatic glands in various parts, chiefly 
where the lupus process is most active; the swelling, as a rule, 
does not last long, but returns with each exacerbation, but sup- 
puration is rare. (5) The persistent erysipelas-like condition 
of the face, already mentioned, which is very liable to lead to 
a typhoid state and a fatal issue, or genuine erysipelas or lym- 
phangitis, which may spread rapidly over a wide area and en- 
danger life, or be limited or transitory. When erysipelas is 
severe it aggravates the lupus disease, but complete involution 
of the lupus may ensue, in this as in the chronic form, when 
the erysipelas lasts for some time. 

The more chronic cases may have no defect of the general 
health, or there may be tuberculosis, anemia, uterine or other 
derangements, either combined or alternating with the exacer- 
bations and remissions. 

In the third, or telangiectic, form,* which Kaposi does not 
appear to recognize, there may be no marked change of the sur- 
face, except a persistent circumscribed redness, which close in- 
spection shows to be due to dilated vessels. It may be single, 
but is commonly situated symmetrically on both cheeks, very 
much of the size and shape of the red patch which the circus 
clown paints on his face (the flush patch of Hutchinson), and 
is not very noticeable to the eye, but on pinching up the tissues 
there is marked thickening. Sometimes a few comedones may 
be present, but they are never conspicuous, and there is no 

* Author's Atlas, Plate LXXI., Fie;. 2. 



820 DISEASES OF THE SKIN. 

desquamation. These cases run a very slow course, and may 
remain for years with very little alteration. If involution 
should occur, a little streaky superficial scarring would probably 
be left. I have seen it associated with the usual form on the 
scalp. For Hutchinson's Nevus lupus, see Angioma serpigi- 
nosum. 

The nodular form is very rare, and was first described in my 
second edition. I have seen several cases, and all but one in 
adult women; the youngest was a lady of thirty-four, who Had 
had a red patch on the side of the nose, and the nodule devel- 
oped on this a few months previously. In one of the most 
marked cases, about a score of roundish or oval, convex, dis- 
tinctly raised nodules, from a hemp seed to a small bean in size, 
were scattered over the upper part of the face, nose, and lip. 
They were of brownish-red color, very like L. vulgaris, but 
there were one or two on the auricle flatter and more like ery- 
thematous lupus, and on the back of the right hand there were 
two or three commencing nodules. A group on each side of the 
forehead, at the border of the hair, coalesced into a small patch, 
which was flattened in the center, leaving a prominent rim, and 
subsequently was slightly cicatricial. The nodules enlarged 
very slowly, and showed very little tendency to undergo central 
involution. The patient was a stout lady of forty, dyspeptic, but 
with no organic disease in herself or her family. Subsequently 
all the patches involuted, apparently spontaneously. In a third 
case, an elderly woman, there were bean-sized patches scattered 
over the whole face; they were distinctly raised, and remained 
unchanged for years. Another case was in a man, aet. fifty- 
eight, who had three small nodules on the left lower eyelid, 
and another on the cheek; they were destroyed by electrolysis. 
Individually the lesions are often remarkably like a single nod- 
ule of L. vulgaris, but from their general behavior and distribu- 
tion it seems more probable that they belong to this type. 

Pringle * showed a case at the Dermatological Society of 
London, a woman, set. fifty-four, with cancer of the uterus and 
symmetrical nodules on the nose, cheeks, and ears. 

On the hands and feet, especially on the fingers and toes,f 

* Brit. Jour. Derm., vol ix. (1897), p. 201. 

f Nevins Hyde, " Lupus Erythematosus as it affects the Hands: a Clini- 
cal Study," in Amer. Jour. Cut. and Ven. Dis., vol. ii. (1884), p. 321— a 



LUPUS ERYTHEMATOSUS. 821 

often affecting only the back of the terminal phalanges, but 
present elsewhere occasionally, the disease may begin as a per- 
sistent erythema, often looking like chilblains, but generally 
with some scaliness; but when involution occurs, whether spon- 
taneously or as the result of treatment, there is always more or 
less atrophic scarring, though sometimes it is so slight as to 
be only in whitish streaks in the healthy skin. It may also be 
seen as plaques, with a horny adherent crust and a red border; 
painful fissures are apt to occur in this form, from loss of elas- 
ticity of the skin and the constant movement. In these cases 
the sebaceous glands are not primarily involved, and indeed 
it may occur in parts where there are no sebaceous glands, such 
as the palms and soles. It is rare on the mucous membranes of 
the cheek and hard palate, where it is seen as soft red or gray 
exudations or whitish scars. I have had well-marked cases. 
Dubreuilh,* Galloway, and Leslie Roberts have recorded in- 
stances. I have also seen it as irregular but superficial ulcera- 
tion of the center of the tongue, while on each side of the raphe 
were whitish pea-sized areas surrounded by a zone of deep red- 
ness. They were closely aggregated, but discrete. Audry has 
also had a case affecting the tongue, in the form of two bright 
red symmetrical patches level with the rest of the surface. 

The course of L. erythematosus is, as a rule, very slow; cases 
may last for ten or twenty years, spreading slowly, but often 
with long intervals of quiescence; but it is always liable to more 
rapid development. On the other hand, many cases get well 
spontaneously or as the result of treatment; and Hutchinson is 
of opinion that cases tend to get well as old age approaches, 
but I have seen it in septuagenarians. 

good paper, with a table of thirty-five cases on the hands, and resume 
of previous observations. Ohmann-Dumesnil collected forty-five cases; 
in twelve it began on the face, in the rest on the hands. The lesions, as 
a rule, affect the dorsal surface of the fingers, and do not extend beyond 
the nails. Ninth Intern. Med. Congress, 1887. The Sydenham Society's 
Atlas, Plate XLII., shows the erythematous form, and Tilbury Fox's 
Atlas, Plate XLV., Fig. 2, the crusted form, very well. A vascular ery- 
thematosus form is shown in Plate LXVIL, Figs. 3 and 4, of my Atlas; 
but Figs. 1 and 2 I now consider are not lupus erythematosus. ( Vide 
Granuloma Annulare.) 

* Dubreuilh gives a review of cases in Annates de Derm., vol. i. (1900), 
p. 231. 



822 DISEASES OF THE SKIN. 

Chilblain Lupus — Lupus Pernio. Hutchinson has described 
cases under the first name, and Besnier and some subsequent 
French writers cases under the second name. 

Hutchinson's cases are forms of lupus erythematosus like 
those above mentioned. They attack chiefly the fingers and 
toes, and next the nose and ears, but may also involve other 
parts of the face and forearms, and may affect them more se- 
verely than in the usual situations. They form well-defined per- 
sistent purplish, red patches, with or without scaliness, and es- 
pecially affect the knuckles and terminal phalanges. They are 
at first excited, and always aggravated, by the winter's cold, 
and ameliorate, but do not disappear in the summer, except 
in some cases at an early stage. 

Besnier's Lupus pernio * is another form which occurs in per- 
sons with a weak circulation, the eruption being en nappe, but 
on close examination, with the skin slightly scratched, a fine 
nodular composition is revealed. Hutchinson says this is quite 
different from his cases, and thinks it is a L. vulgaris in a per- 
son with weak circulation. Tenneson has seen it associated 
with lupus vulgaris, and has noted dilatation of follicular 
orifices. 

Complications. — Hutchinson has drawn attention to the occa- 
sional occurrences in cases of long-standing lupus erythe- 
matosus of the scalp of an acneiform eruption on the shoulders. 
These lesions sometimes spread at their borders, and thus as- 
sume lupus characters; in one case there were half-inch patches 
made up of groups of little red lichenlike papules, some with 
evidence of scar formation. 

In Plate LXL, Fig. 3, of my Atlas, a breast is depicted on 
which were persistent scaly lesions one-eighth inch in dia- 
meter, like a psoriasis punctata; on the back of this patient be- 
neath the scapulae were somewhat similar lesions, but, instead 
of being persistent, they only came out in the spring and au- 
tumn, and after lasting six weeks disappeared. 

Galloway had a case of a woman of forty-five with L. ery- 
thematosus of fifteen years' standing, in which the scalp lesions 
developed bullce, which coalesced and extended to the margin of 

* Plates XVIII. and XXXV., St. Louis Atlas, and the text. See also, 
discussion on a case shown by Tenneson, Annates de Derm, et de Syph., 
vol. iii. (1892), p. 1142. 



LUPUS ERYTHEMATOSUS. 823 

the affected area. The contents were limpid or turbid. After 
six weeks the bullae ceased, and the surface healed without ex- 
tension of the lupus. The face lesions were unaffected. 

Epithelioma may develop in the cicatrices of L. erythematosus, 
as it may in those of L. vulgaris, but far less frequently. A 
case is depicted in Kaposi's Hand-Atlas, Plate XCIX.,* on the 
upper lip, and Pringle f has recorded a case in which multiple 
epitheliomata developed on the scalp and recurred several times 
after free removal. Hollaender i also has had a case. 

Erysipelas and its effects have already been mentioned. Sev- 
eral cases of folliclis of the hands associated with it have been 
observed by Hallopeau, myself, and others. Hallopeau has also 
seen spontaneous follicular suppurations and intensely destruc- 
tive acneic lesions near the patches. 

Etiology. — It is very much more common in females than 
males in hospital practice, and in my private practice it 
is over five to one (eighty-five to sixteen), and occurs 
chiefly between the ages of eighteen and forty-five years, 
while it is never seen in infants, is rare in children and in 
old age. The oldest, in my experience, was a woman 
of seventy-one, in whom it had commenced in the hand 
two years before, and the youngest was six years old; but 
Kaposi records a case in a child of three years. Speaking 
broadly, its period of earliest onset coincides with the cessation 
of the liability to a primary attack of L. vulgaris. The etiology 
is, however, obscure for the most part. A history of phthisis 
in the family is frequent — Hutchinson says even more so than 
in L. vulgaris, but I should not go so far as that. § I have also 



* Kreibich gives the history of this case, and reproduces the illustration, 
Archiv f. Derm. u. Syph., vol. li. (1900), p. 347. 

f Brit. Jour. Derm., vol. xii. (1900), p. 1, with colored plates, and refer- 
ences to other cases. 

\Zeitschrift f. Derm., vol. vii. (1900), p. 962. 

£ Sequeira's statistics of 71 cases at the London Hospital corroborate 
these statements. Eighty-five per cent, females to fifteen males, 56 
out of the 71 between sixteen years and forty, 7 over forty, 8 under 
fifteen, and the extremes were eleven and fifty-eight years. A family 
history of phthisis in 34 out of 71, but in 11 disseminated cases 8 had 
phthisis in the family. There was evidence of tuberculosis in the 
patient, in 7 out of 11 of the disseminated cases, but in the discoid cases, 
3 out of 60 cases had phthisis, 7 had strumous glands, and 1 hip disease. 



824 



DISEASES OF THE SKIN. 



thought that uterine derangements possessed an etiological im- 
portance. A feeble circulation is a favoring influence, and not 
infrequently the disease dates from some form of superficial 
inflammation, such as scarlatina or erysipelas. Prolonged ex- 
posure to great heat in the sun, or to great cold, especially cold 
winds, has appeared to be the exciting cause in some of my 
cases. The association of copious albuminuria with the diffuse 
form is too frequent to be fortuitous, but does not explain the 
pathology of the disease. Sometimes it follows smallpox, and 
it is said that persons with light skin and hair are more liable 
to it than dark-complexioned people. Its much greater fre- 
quency in the well-to-do as compared with L. vulgaris is note- 
worthy. 

Pathology. — The disease is generally considered to have no 
pathological relation to L. vulgaris, but some authors * still 
regard it as a form of tuberculous disease, and there are cer- 
tainly cases in which the two forms of disease seem to approach 
each other, in clinical characters at all events. Anatomically 
the lesions are indistinguishable from an inflammation of the 
cutis, in which the infiltration elements undergo fatty degenera- 
tion and lead to the atrophy of the tissue in which they are 
deposited. No tubercle bacilli have ever been found, f and at- 
tempts at inoculation of animals have always failed. 

It has been suggested that it might be due to the toxin of 
tubercle; but against this is the fact that, in the early days of 
tuberculin for lupus vulgaris and phthisis, thousands must have 



In 2 of the acute disseminated cases, local irritation, viz., poultices to the 
abdomen, and the light treatment respectively, brought out the eruption. 
Five out of 10 diffuse cases had albuminuria. Brit. Jour. Derm., vol. 
xiv., 1902. 

* C. Boeck opened a discussion in Edinburgh, in which he set forth the 
grounds for his belief in the tuberculous origin of lupus erythematosus. 
Brit. Jour. Derm., vol. x. (1898), p. 371. He states that in thirty-six cases 
of discoid L. erythematosus twenty-four showed evident symptoms of 
scrofulo-tuberculosis, and of the other twelve, six had near relations who 
were tuberculous. He also says that, as in macular anesthetic lepra, the 
patches of L. erythematosus are distributed in the course of nerves. 
Neither of these statements is borne out by English experience. See also 
the discussion on Tuberculids at Thirteenth Internat. Cong, at Paris, 
1900, by Boeck, C. Fox, Campana, etc. 

f Audry found them in a case of the disseminate form in two lesions, 
and none in a third, but all observers have failed. 



LUPUS ERYTHEMATOSUS. 825 

had the tubercle toxins injected, and in no recorded case was 
lupus erythematosus produced; moreover, there was either no 
reaction or a very trifling one in all but a very few cases of 
L. erythematosus in which tuberculin was injected. The cases 
are uncommon in which phthisis, generally enlarged glands, or 
lupus vulgaris, or other forms of tuberculosis have been asso- 
ciated with, or have developed in patients with, L. erythema- 
tosus. 

Still, many distinguished observers besides Boeck believe it 
to be of tuberculous origin on clinical grounds. Among these 
may be mentioned Hutchinson, Besnier, Hallopeau, and most 
of the French school, but it is certainly not bacillary. 

The balance of evidence, in my opinion, points to its being 
primarily a vaso-motor disturbance leading to an inflammation 
of the skin, perhaps of toxic, but not of tuberculo-toxic origin, 
especially predisposed to by a feeble blood-current; secondarily, 
there is microbic invasion of the disturbed epithelial layers; 
while in the acute general form there is an additional infective 
element introduced into the system, and especially invading the 
lymphatics. 

Anatomy. — Early observers considered, on clinical and pathological 
grounds, that the disease was primarily situated at the sebaceous or 
sometimes the sweat glands. Geber and Strogamn confirmed by Schiitz, 
Unna,* etc., say that the disease commences in the papillary or deeper 
layers, and affects the gland structures secondarily. 

According to Unna there are primary epidermic changes, hyperkera- 
tosis on the scalp, forehead, etc., or acanthosis (prickle cell growth), but 
not with downgrowth of the papillary processes, for it is compressed 
between the cellular growth in the cutis below and the increased cornifi- 
cation above. The horny plugs may or may not correspond with the 
follicular orifices, but when they do, the cells of the sebaceous glands 
undergo fatty degeneration, and finally atrophy (Schiitz), and the horny 
pegs fill the vacancy. The blood-vessels of the cutis are surrounded by 
sheaths of plasma cells which soon atrophy. The cells are of nearly 
uniform size, and multi-nuclear and giant cells are absent, distinguishing 
it from lupus vulgaris and syphilitic lesions. According to Unna, at the 
height of development the cellular areas are composed of almost cubical 
cells at the periphery and round ones at the center, all with a large 
round or oval deeply-staining nucleus surrounded by a fine regular shell 
of deeply-staining protoplasm. Inside the cell masses are channels of 
enormously dilated lymph spaces, due to " insulated liquefaction of 
cellular territories." There is also marked edema of the cell areas. The 
elastic tissue of the affected area is for the most part preserved. 

*" Histopathology," p. 1071, under Ulerythema Centrifugum. 



826 DISEASES OF THE SKIN. 

Unna sums up the characteristic features as follows: 

" The formation of areas of inflammatory cellular new 
growth; the disappearance of the latter and of the collagenous 
tissue in favor of the dilating lymph system; the primary hyper- 
keratosis with or without epithelial growth and its results; the 
edematous changes with hyalin swelling of the inflammatory 
body and prickle layer; and the formation of peculiar plug- 
carrying scales, with stoppage of the follicles and ultimate 
atrophy of the cutaneous structures. In the lupus pernio of the 
fingers, great hyperkeratosis is the main feature, with resulting 
pressure atrophy of the subjacent structures." 

Schoonheid * has examined twelve cases histologically. He 
regards the disease as a chronic inflammatory process rather 
than a granuloma, and thinks the process begins in the rete, 
followed by a perivascular infiltration round the subepithelial 
vessels. The process extends upwards and downwards and 
round the appendages of the skin. It consists at first of leu- 
kocytes, but later there is proliferation of connective tissue 
cells, and the infiltration becomes more diffuse. There are some 
mast cells, but the proportion varies. Plasma cells are only 
found at the periphery of the foci, never in the central part. 

Diagnosis. — It is very protean in its manifestations and often 
imitates other diseases,f so closely sometimes as to require the 
greatest care in its diagnosis; and even the most experienced 
are sometimes deceived until further development reveals the 
true character of the eruption. The most characteristic features 
are — the age at which the disease begins; its slow course, its 
symmetry, and the position of the superficial patches on the 
cheeks and nose, ear tips and scalp; the sharply defined bor- 
der; the closely adherent scales with processes dipping into the 
sebaceous orifices; the absence of ulceration; and the presence 
of more or less atrophic scarring, while there are no papules 
or nodules. In all these particulars, except the slow course, it 
differs from L. vulgaris, to which it has some clinical resem- 
blances, especially in adults, in whom nodulation is often incon- 
spicuous or absent. L. vulgaris erythematodes of Leloir is the 
only form difficult to distinguish. (See that disease.) 

* Archiv f. Derm. u. Syph., December, 1900, p. 163. Good abs. Brit. 
Jour. Derm., vol. xiii. (1900), p. 159. 

f See for further details a paper by the Author, " Lupus Erythematosus 
as an Imitator," Amer. Jour. Cut. and Gen.-Ur. Dis., vol xii. (1894), p. 1. 



LUPUS ERYTHEMATOSUS. 827 

Less typical instances, where the scaliness is more abundant 
than usual, may be mistaken for psoriasis. This resemblance is 
so great, in some instances, that Mr. Hutchinson believes in a 
hybrid condition of " lupus-psoriasis." * S. Mackenzie showed 
such a case at one of the societies, and Dr. Xeale of Leicester 
sent a young woman to me (whose sister was subject to ordi- 
nary psoriasis), who had indubitable L. erythematosus of the 
face, while on the forearms there had been an eruption like 
psoriasis, which was cured with chrysarobin ointment, but left 
scars. It must, however, be borne in mind that scarring is in 
rare instances left in true psoriasis. In a lady of thirty who 
had had psoriasis on her elbows which left scars, when I saw 
her she had typical lupus erythematosus of the ear lobes and 
left cheek. Her brother suffered from ordinary psoriasis. 

Similarly, the appearance of eczema may be produced, which 
Hutchinson calls " eczema-lupus." The sharply denned border 
in lupus should excite suspicion, and on attempting to remove 
the crusts in an acute case, or the scales in a chronic one, they 
will be found firmly adherent, and sending processes down into 
the follicular openings. Here, too, if the disease is of some 
standing, more or less scarring will be present. In the chronic 
cases the slow development, the greater infiltration, and the 
trifling variations in intensity will give the right clew. Tilbury 
Fox also described an acne lupus, or " lupoid acne," but this has 
nothing to do with L. erythematosus. On the hand, especially 
on the fingers, it may be mistaken for chilblains. The distin- 
guishing features are the persistence of the lupus patches 
through the summer, and the slight scaliness. Sometimes 
there is slight streaky scarring on the backs of the fingers, 
sometimes a central depression and atrophic scarring, which, 
affecting the pulp of the finger, renders it conical and blood- 
less. Cases with thick, yellowish, horny flakes covering the 
patch offer little difficulty in diagnosis. 

These compound terms are better avoided, although, as 
before said, ordinary inflammations do sometimes seem to be 
the exciting cause of the lupus inflammation, and L. erythema- 
tosus frequently imitates simple inflammations, such as ery- 
thema exudativum, chilblains, etc., besides those already men- 

* Clin. Soc. Trans., vol. xv. (1882), p. 252, colored plate. He considered 
that it was lupus vulgaris. In this case also a sister had ordinary psoriasis. 



828 DISEASES OF THE SKIN. 

tioned. The telangiectic cases are like acne rosacea in some 
respects, but the symmetry on the malar eminences, the ab- 
sence of papules or pustules, and the induration and persistence 
are distinguishing features, and there is no scarring in acne 
rosacea as a rule, except from the larger acne pustules. 

Indeed, the cicatrices will distinguish it from any other in- 
flammatory infiltration, except some of those due to syphilis. 
In them there is more deposit and less vascularity than in the 
lupus, and they run a more acute course. The scarring of 
hydroa vacciniformis may sometimes suggest L. erythematosus, 
but the antecedent vesicular lesions and the intermittent sum- 
mer course would be reliable guides. 

Prognosis. — The more the disease resembles an ordinary 
dermatitis, i. e., the highly erythematous cases, the more often 
they are amenable to treatment; and sometimes they involute 
spontaneously, the scarring being in proportion to the depth 
of the infiltration. In the chronic limited patches, although 
often obstinate, great improvement can always be obtained and 
a cure sometimes effected, but very seldom without leaving a 
scar. In the acute or subacute diffuse eruption it is impossible 
to tell at once what will be the result, but it is so often fatal 
that it is essentially a grave disease, and a guarded prognosis 
is all that is possible. White * of Boston is very pessimistic for 
all forms, but, as Hutchinson has pointed out, there is a tend- 
ency to get well in the course of a long time, as it seldom lasts 
into old age. 

Treatment. — The internal treatment is not very satisfactory. 
Arsenic is relied upon by some, and Hutchinson records a sin- 
gle case in which it was apparently the curative agent, A case 
which I saw with my colleague, Mr. Battle, also got well with 
arsenic, no local treatment having been employed; but these 
cases are too exceptional to give much credit to the drug. Mc- 
Call Anderson advocates the iodid of starch as curative in some 
and beneficial in many cases. It is made by triturating twenty- 
four grains of iodin with a little water, and then gradually add- 
ing an ounce of starch, rubbing them well together until the 
mass becomes of a deep blue color. It is then dried with a very 
gentle heat, and a heaped teaspoonful is given in water or gruel 
three times a day. The dose may be safely increased up to an 
* [our. Cut. Gen. and Ur. Bis., vol. xvi., October, 1898. 






LUPUS ERYTHEMATOSUS. 829 

ounce. The iodid should be freshly prepared and kept in a 
stoppered bottle. I have not had success with it. Iodid of 
potassium also has its advocates; others, notably Bulkley, be- 
lieve in phosphorus 1-50 to 1-30 of a grain three times a day. 
Payne gives large doses of quinine, twelve to thirty grains a 
day. I have had far better results with salicin internally than 
with any other drug. Beginning with a dose of fifteen grains 
three times a day it may be increased, except in the few cases 
in which the patient is intolerant of it, to twenty or even thirty 
grains a dose. It is most likely to be successful in the actively 
inflammatory cases, and, like every other drug, generally fails 
in the chronic cases with a few indolent crusted patches. How- 
ever, as it can do no harm, and other drugs so rarely do any 
good it is worth trying in nearly all cases. I have also given 
ichthyol, in five-minim doses in the form of pills or capsules, 
three times a day after meals, and thought that it had some 
effect in reducing the hyperemia, but all direct remedies are 
only too likely to be disappointing. When they fail I rely 
chiefly on those measures which will best promote the general 
invigoration of the patient, seeking for indications of anemia, 
tuberculosis, gout, dyspepsia, uterine or ovarian irritation, etc., 
and endeavoring to correct such errors, and, for the rest, ad- 
dress myself to efficient local treatment. 

Locally. — In all cases the affected parts should be protected 
against any sudden or great alterations of temperature and 
against any local irritation, especially of sun and cold winds. 
The local applications come under soothing astringents, such as 
lead and zinc applications. 

Compressing agents, such as collodion. 

Discutients, such as soft soap, liquor potassse, and salicylic acid. 

Bactericidal applications, such as perchlorid of mercury, iodo- 
form, etc. 

Caustics, such as acid nitrate of mercury, Paquelin's cautery; 
surgical means, such as scarification, erasion, and electrolysis, 
and the light treatment. 

Considerable judgment, to be gained only by experience, is 
necessary for the choice of the best method for any particular 
case of this obstinate disease; but it should always be borne in 
mind that, wherever there is active hyperemia, this should be 
subdued bv such means as would be employed in cases of drv 



830 DISEASES OF THE SKIN. 

dermatitis of any form before the more special measures are re- 
sorted to. Any application which irritates is only too likely to 
make the disease spread, and that often at a most alarming rate. 

If the inflammation is active, calamin or lead lotion — either 
the undiluted solution of the acetate, the glycerole, or the lac- 
tate of lead — may be painted on twice a day or more, and the 
emplastrum hydrargyri worn at night. 

Collodion, not the flexile, has also given good results in my 
hands by compressing the vessels. Unna advocates ichthyol 
preparations, such as zinc ichthyol salve muslin at night, after 
fomenting with hot water. Unna's iodoform gutta-percha 
plaster muslin is also a good application for limited areas. 
Where there is less hyperemia, a lotion of sulphid of zinc, as 
recommended by Duhring, suits some cases. It consists of 
sulphate of zinc, sulphuret of potassium, of each thirty grains, 
alcohol oiij, and rosewater §iv. The zinc and potassium should 
be dissolved separately, and then mixed. Hans Hebra recom- 
mends dabbing with pure alcohol many times a day; its evapo- 
ration produces by cold a contraction of the blood-vessels 
which is very beneficial. 

In cases with the horny adherent crusts so common in the 
so-called sebaceous form on the nose and cheeks, an excellent 
treatment is that recommended by Hebra. The spiritus sa- 
ponatus kalinus is rubbed on firmly with a piece of lint or 
flannel. This removes the scales and fatty plugs, and if done 
thoroughly there is some oozing of blood and serum, which 
dries into crusts, and these fall off in a few days, or sooner if 
soaked in oil. The process is then repeated, and sometimes, in 
a few weeks, a limited patch may be quite removed without 
even leaving a scar. It is especially useful in parts like the eye- 
lids, where the skin is thin, and also before and after more 
severe applications; oil of cade oj or 3ij to the 5j is a useful addi- 
tion sometimes. Soft soap is a similar remedy, and may be 
used continuously spread on lint, and acts then as a mild 
caustic. Neither soft soap nor the spirit soap should be used 
where there is active congestion, or they will very likely ag- 
gravate the eruption. Painting with liquor potassse acts in a 
similar way; after a couple of minutes it may be washed off and 
boric acid ointment applied. Great care is necessary to get 
success without injury. 



LUPUS ERYTHEMATOSUS. 831 

A milder and more generally applicable treatment with a 
similar idea is moderate friction of the part with benzolin, as 
recommended by Hutchinson, followed by a mild antiseptic oint- 
ment, such as iodoform gr. 5 to §j or boric acid. I can speak 
in the highest terms of this treatment, except where there is 
great hyperemia. It should be used at night, and calamin lo- 
tion applied in the daytime; but if the benzolin produces any 
irritation it should not be rubbed in more than two or three 
times a week. 

Coming to stronger remedies: For limited surfaces Payne's 
treatment with salicylic acid, three to six per cent, in collodion, 
often gives excellent results. Unna uses ten per cent, resorcin 
in collodion. It is safer to use not more than two per cent, at 
first, as resorcin appears to form some kind of compound with 
collodion, which sometimes acts as a strong caustic. 

Richardson's sodium ethylate, carefully painted on, may be 
used for small patches, care being taken to keep the part dry 
afterwards till the eschar has separated. Chloracetic acid, ap- 
plied with a glass rod, is a rapid superficial escharotic and not 
very painful, and is highly spoken of by Veiel, while for larger 
surfaces he prefers a ten per cent, pyrogallic acid ointment, 
applied for three or four days or until a brownish superficial 
eschar forms, when it is covered with an iodoform bandage until 
the slough separates, and the wound is then dressed with iodo- 
form. I prefer carbolic acid in crystals or combined with equal 
parts of camphor to any other caustic, as its action is super- 
ficial and not painful after a few seconds. 

Schiiltz recommends painting with liq. Fowleri four parts, aq. 
distillatse thirty parts, with chloroform TTtij, to prevent the solu- 
tion from getting moldy. He paints it on every day for five 
days, which produces swelling, redness, and tenderness; this 
is subdued with a soothing astringent, such as calamin, and 
then painting with the arsenical solution is resumed. A cure 
results in two to three months. Other methods with more or 
less good credentials are: painting with oleum rusci or cadini, 
or glycerin of iodin, composed of 5j of iodin, 3j of iodid of 
potassium, and oij of glycerin. Arsenical paste is also effectual 
for obstinate cases, but is very painful, and burns rather deeply. 
Purdon cured a case by painting with a three per cent, solution 
of resorcin, and covering with an india-rubber mask. For my 



832 DISEASES OF THE SKIN. 

own part I try calamin lotion, collodion, with or without 
salicylic acid, mercurial plaster, benzolin, and sometimes the 
spirit-soap treatment, and if good results are not obtained, I try 
linear scarification, as recommended by B. Squire, with his in- 
strument, a bundle of knives, constructed to make parallel 
incisions one-sixteenth of an inch deep. These incisions are 
then crossed in two or three directions, and iodoform well 
rubbed in. The division of so many vessels effectually starves 
the disease, the bactericide adds to the good effect, and great 
improvement results. The operation requires repetition several 
times. Veiel's instrument, as improved by Pick (Fig. 45), is on 
the same principle, and makes either punctures or cuts, and is 
well adapted for awkward corners, such as the angle of the nose 
and cheek and about the orbit, where Squire's instrument does 
not readily reach. The operation leaves scarcely any scar, and 
can be done either under local anesthesia or nitrous oxid gas, 
where the area is not very great. This method is as great an 
advance in the treatment of this obstinate disease as erasion is 
for L. vulgaris, and almost supersedes caustics, which are pain- 
ful and uncertain in the depth of their action. In deep-seated 
cases erasion may be preferable, as it shortens the treatment. 

Lassar prefers Paquelin's thermo-cautery or the galvano- 
cautery, scarifying lightly the affected area, so that only a thin 
eschar is produced, an antiseptic powder being dusted on after 
the operation. Only a small area should be done at one sitting. 

Schiff removed nearly all the disease in a very extensive case 
by means of the Rontgen rays, which he employed for two 
months with an exposure of ten minutes a day. It is worth try- 
ing in a suitable case, but care must be exercised so as not to 
set up a suppurative dermatitis, using two to five amperes and 
a six-inch tube at a distance of about four to six inches. In 
one very obstinate case I obtained great improvement by con- 
tinuing exposures until slight redness was produced, then 
soothing the inflammation, and when it had entirely subsided 
beginning again with the exposures. A very obstinate ulcera- 
tion of the nose healed soundly under this treatment. 

The Finsen treatment can also be used with great advantage 
sometimes, but in a much smaller proportion of cases than in 
lupus vulgaris, and permanence of result is much less likely to 
be obtained; but this is the same for any treatment. Limited 



LUPUS ERYTHEMATOSUS. 833 

indolent cases — the " fixed cases," as Brocq calls them — are 
the most likely to be improved by it. Still better than either 
the Rontgen or the Finsen rays, according to Oudin and Brocq, 
are the high frequency currents, and if any large proportion of 
what is said of it is true, it will prove a great advance in the 
treatment of the most intractable form of case. Jacquet states 
in his thesis that in thirty-one cases in Brocq's clinic there were 
twenty-five cures. Xo other treatment hitherto brought for- 
ward can approach this, but it is unlikely that in anything lfke 
this number the cure was permanent. My own experience is at 
present too limited to speak of it first hand. Radium-therapy 
is mentioned in the treatment of lupus vulgaris. 

Lupus Marginatus. This name has been given by Hutchin- 
son to a disease which spreads up to a certain point and scars 
superficially, but in other respects differs from other forms of 
lupus. He records three cases.* 

Two of the cases, a boy and girl, began in early childhood; 
the third, a woman, aet. forty, began when set. thirty-four. The 
patches were circular or gyrate. They were abruptly margined, 
had papular borders, and showed a thin pale cicatrix in their 
areas. In the boy they were freely scattered over the lower 
part of the face, sparse on the forehead, and were not sym- 
metrical. The circles and ovals extended in a streak down the 
ulnar border of the left forearm and side of the hand, and there 
were a few circles on the arm. The girl's had a similar distribu- 
tion, but there were none on the face. About twenty rings were 
scattered over the woman's face. The papules of the border 
were not larger than a pin's head, and the scarring of the area 
very superficial, and there was no erythema. They were stead- 
ily but slowly increasing in size, but gave no trouble. There 
was a strong phthisical family history. The nosological posi- 
tion of the condition is doubtful, and it is placed here pro- 
visionally. 

Lupus Telangiectodes Disseminatus. Majocchi * describes 

* Hutchinson's Smaller Atlas, Plates XIII. and XIV., and Archives, 
vol. i. The cases are in Clin. Jour., December 12, 1894, p. 114. 

\ Berlin klin. Wochensch., May 14, 1S94. Abs. in Annates, vol. vi. 
(1894), p. 151. Possibly Hutchinson's Lichen Lupus, Smaller Atlas, 
Plate CVIII., is an example. 

53 



834 DISEASES OF THE SKIN. 

a rare form of disease under this title. The extreme vascu- 
larity is its most distinguishing feature. There are numerous 
reddish or bluish-red ill-defined patches on which occasionally 
flat or slightly projecting papules develop. These tend to 
atrophy, while numerous small vessels, forming fine reticula- 
tions, ramify in all directions. The patient, a girl of twenty- 
three, had always suffered from chilblains. At sixteen the chil- 
blains of the feet reached up to the lower third of the left leg, 
and formed numerous isolated papules, which had invaded two- 
thirds of the lower circumference of the malleoli. During the 
next six winters the disease extended over the whole leg and 
thigh and affected the other leg. When seen the eruption was 
limited to the lower limbs, principally on the outer side of the 
extensor aspect; they began at the top of the thighs and ex- 
tended symmetrically to the ankles. They were made up of 
patches from the size of the palm to a drop or small coin, and 
were lenticular in outline. There were eleven patches on the 
right and six on the left leg. The smaller were bright or 
pinkish-red, the larger bluish-red. The skin was more or less 
infiltrated, but there was scarcely any projection. Round the 
patches, especially on the hips, there were distinct nodules of 
soft consistence and variable size. Near the papules, or where 
they had formed, were atrophic cicatricial depressions like len- 
tils or drops, round or oval, and often surrounded by a slight 
pigmented areola, especially situated at the periphery of the 
large plaques. With a lens the patches showed fine dilated ves- 
sels, from which projected very numerous larger ramifications 
of a bright color, radiating from the center to the periphery, 
ending sometimes abruptly at the border of the patch, some- 
times extending beyond it. According to De Amicis, the evolu- 
tion, which is very slow, has an erythematous and telangiectasic 
period. At first bright red, later deep red spots appear. In the 
center of these a network of myriads of fine capillaries appear, 
and slowly spread, sometimes even to the periphery. In some 
spots develop irregularly and extend in the form of tufts or 
rays. The lupus spots are of a bright red color and do not 
disappear on pressure, and in some papules infiltration devel- 
ops. The infiltrated vascular parts and the deep-seated nodes 
sometimes atrophy and leave superficial cicatrices. 



SYPHILIS. 835 



SYPHILIS. 

Synonyms. — Sibbens or Sivvens; Radezyge; Scherlievo; 
Mai de la Baie de St. Paul. 

These names were given to unrecognized syphilis which oc- 
curred in an endemic form in Scotland, Norway, the east 
Adriatic coast, and Canada respectively. They are now almost 
disused. 

Definition. — A chronic, specific, contagious, hereditary, and 
protective exanthematous disease, which may produce lesions 
in any tissue of the body, and is in many respects analogous to 
leprosy, but tends to get well. 

Although this work is concerned mainly with the skin mani- 
festations or syphilodermia, an outline of the early symptoms 
will not be out of place, as they must be taken into considera- 
tion in the diagnosis. The classification of the symptoms into 
primary, secondary, and tertiary periods of disease is con- 
venient for description, and true in the main, although arbi- 
trary and ill-defined in some respects, since the secondary and 
tertiary symptoms often merge into each other, and while, on 
the one hand, symptoms which usually occur late in the dis- 
ease are occasionally among the early manifestations, on the 
other, some secondary symptoms recur at a late period. 

The period of incubation, or the time which elapses between 
exposure to contagion and the development of the initial lesion, 
is usually three to four weeks, but the extremes are twenty-four 
hours (R. W. Taylor), and eighty-one days (Pusch).* There 
are, however, few cases which occur outside the limits of two 
to six weeks. 

The initial manifestation may be: (1) A desquamating 

* Jour, des Mai. Cut. et Syph.. July, 1890; Pusch gives many cases, 
including a case of ninety-seven days, but it was not quite conclusive — 
the girl had an intervening variola. Also abstract by Brocq, Amer. 
Jour, of Cut. and Gen.-Ur. Dis., vol. viii. (1890), p. 492. Mackenzie 
Forbes of Montreal sent me an account of a case much longer than these, 
viz., from the beginning of October to March 7. The patient contracted 
gonorrhea at the same coitus, and it is suggested that the coincident 
urethritis delayed the syphilitic manifestation.— J/<?;z/r^#/ Med. Jour., 
December. 1899. 



S36 DISEASES OF THE SKIN. 

papule; (2) a superficial erosion with indurated base; (3) an in- 
dolent ulcer with a hard base extending beyond the sore, " the 
true Hunterian chancre." In the case of a surgeon * who 
inoculated his finger in an operation by a direct blood inocula- 
tion there was no primary sore, but the first symptoms began 
twenty-six days afterwards and the macular rash on the thir- 
tieth day. 

In at least ninety per cent, of all cases the initial lesion is 
on or about the genitals, but there are few parts of the body 
on which it is not recorded to have occurred. In estimating 
the value of a negative history, it is important to remember 
that the primary lesion and the early symptoms may be so 
slight as to be unnoticed or soon forgotten by the patient. The 
next phenomenon to the sore is the enlargement of the lym- 
phatic glands in the neighborhood and even elsewhere, which 
usually begins about ten days after induration round the sore, 
and may not entirely subside for a year or more. Between the 
time of the appearance of the initial lesion and the general 
eruption there is a period of quiescence of from 40 to 50 days 
as a rule (with extremes of 25 to 160 days), or a month or six 
weeks after the enlargement of the lymphatic glands. 

Symptoms. — Some of the following symptoms of general dis- 
turbance usually, but not always, precede the rash in a varying 
degree of severity: transitory shivering and pyrexia, with the 
usual concomitants, malaise, languor, anorexia; marked anemia 
with its usual symptoms; pains and tenderness of all the super- 
ficial bones, especially the clavicles, ulnae, and tibiae; headache, 
often unilateral, and most intense and distracting; neuralgia, 
especially about the orbit; rheumatoid pains of the muscles, 
joints, and even ears, and occasionally epileptiform fits, tem- 
porary insanity, or various motor or sensory disturbances, in 
one case severe itching; f all these symptoms being aggravated 
at night. The fever is present in a large proportion of cases, 
and may be dependent or independent of the rash. The inde- 
pendent form occurs in from six to nine months after infection, 

* Recorded by Jullien in Neumann's " Festchrift." Abs. Brit. Jour. 
Derm., vol. xiii. (1901), p. 390. 

f Case recorded by L. Derville. The itching preceded the eruption, 
which was at first purpuric for a fortnight and persisted for another two 
or three weeks. There was albuminuria. Full abs. of case, Brit. Jour. 
Der?n., vol. ix. (1897), p. 175. 






SYPHILIS. 837 

and may be continuous, intermittent, or irregular. In the other 
kind the temperature is not generally high, but may reach 
104 F. or 105 F. in the evening, with a morning fall of 2° or 3 
and even 6° (B. Yeo's case), and a pulse not exceeding 120 just 
before and during the development of the rash, the pulse falling 
as soon as the rash is all out.* The fever may precede the 
eruption by three or four weeks. In a few cases the outbreak 
of each crop of eruption is preceded by fever. 

Qn the other hand, it must be borne in mind that in many 
cases the general symptoms are quite insignificant or absent. 

Concomitant Symptoms. — The most common symptoms during 
the early eruption period — i. c, the first year of disease — are 
the primary sore or its scar; the enlarged inguinal, and often 
cervical and occipital glands; the throat, at the least, congested 
and angry-looking, and often ulcerated; there is often very little 
pain unless the ulcer is in a position where it is stretched in 
swallowing; itching of the fauces is sometimes experienced; 
mucous patches or superficial ulcers in the mouth and on the 
tongue; alopecia and lusterless appearance of the remaining 
hair; and perhaps double iritis. At a later period, while in an 
average case, which has been properly treated, the tendency 
to eruptions is less, there may be superficial glossitis and 
stomatitis, and the signs of the previous lesions, whether in the 
skin, eye, mouth, throat, etc., alopecia differing from the early 
kind, and an increased tendency to gummatous deposits in or 
inflammations of the bones, viscera, nervous system, or testi- 
cles, especially of their coverings, e. g., periosteum, capsule of 
the liver, meninges, etc. 

The following tables (pp. 838-41), transcribed from Hutchin- 
son's Illustrations of Clinical Surgery, give a bird's-eye view 
which will assist the student to get a comprehensive grasp of 
this complicated subject. 

* Lancet, Annotation, July 27, igoi, resume of paper by Futcher with 
several cases. One case was tertiary. 



8 3 8 



DISEASES OF THE SKIN. 



Scheme of the Course, Stages, and Sequelae of Acquired Syphilis. 

Antidotal Treatment Supposed to be Abstained from. 

By Jonathan Hutchinson, F. R. S. 



Incubation p er to d. 
Usual duration 3-5 
weeks. 



Development period, or 
Stage of Primary 
Sy nip 1 m s. Lasts 
usually from 2 to 4 
weeks. 



Stage of Secondary 
Symptoms, or Exan- 
them period. All the 
symptoms in this 
stage are usually 
general and symmet- 
rical. Duration from 
a fortnight to 8 
months or more. 



Post Exanthem Period 
= Stage of Latency 
with reminders. 



From date of contagion to first sign of induration 
of the sore. Condition of the site of inocula- 
tion variable according to the purity of the 
poison. If syphilitic virus free from pus, prob- 
ably little or no irritation until just before in- 
duration, when the spot would become for the 
first time red and itchy. 

If, as is usual, pus be mixed with virus, a soft 
sore may be witnessed almost from the first. 
The soft sore has a specific microbe, according 
to some. 



From first appearance of induration to full 
development of secondary symptoms, rash, 
fever, and sore throat. It is usually the first 
part of the exanthem stage. 

Exanthem usually takes from two to four weeks 
to attain full development. 

The symptoms are one or more indurated sores 
and glands in groin. The latter usually not 
inflamed. 



The induration of sore having lasted for two to 
four weeks and still persisting, the patient is 
liable to following symptoms, not all, or in- 
deed any being necessarily present. 

Slight fever, rise of temperature, headache, 
more or less malaise; aching in joints and bones 
with little swelling. Roseolous eruption on 
trunk, followed in a few days or weeks by an 
eruption of papules, pimples, or blotches, 
which sometimes ulcerate and become rupial; 
ulcers on the tonsils, usually with white borders 
and slight superficial sores on the pillars and 
velum of palate; condylomata in throat, on 
tongue, or at arms; iritis; retinitis, with impli- 
cation of the vitreous; loss of hair; slight gen- 
eral enlargement of lymphatic glands. 



The general health is restored, but in exceptional 
cases the patient remains liable to sores in 
the throat, bald patches or sores on the tongue, 
palmar syphilid, etc. Sometimes the second- 



SYPHILIS. 



839 



Scheme of the Course, Stages, and Sequels of Acquired Syphilis. 

Antidotal Treatment Supposed to be Abstained from. 

By Jonathan Hutchinson, F. R. S. — Continued. 



The symptoms in 
this stage are only 
exceptionally sym- 
metrical. It extends 
from the cessation of 
the secondary to the 
beginning of the 
tertiary. 



ary skin eruption is never wholly got rid of, 
but if so it always becomes irregular. Some- 
times there are deep or even phagedenic 
ulcerations, and sometimes a peculiar form of 
relapsing punctate retinitis is seen. Chronic 
sarcocele may occur. The patient may beget 
healthy children. 



Tertiary stage. 

Period of remote 
sequelce. 

In this stage the symp- 
toms are very rarely 
symmetrical. It be- 
gins from 3 to 5, to 10 
or even 30 years after 
the secondary stage. 



Gummatous swellings in cellular tissue, perios- 
teum, or muscle, which may ulcerate and 
spread deeply. They are persistent, and show 
no tendency to spontaneous cure. Diseases of 
the nervous system (arterial disease, or gumma) 
are frequent, and affections of the viscera 
occur. The tendency to phagedenic inflam- 
mation, which may be seen at any stage of 
syphilis, is also frequent now. 



Chronological Statement of Events during the First Year of 
Acquired Syphilis. No Mercury Given. 



1st month. 



2d month. 



Date of Contagion. A little pustule or abrasion, lasting a 
few days, and then healing and perhaps forgotten. Noth- 
ing to be seen, or perhaps a soft sore, secreting pus. 



An insignificant pimple, or perhaps nothing. 

papule which begins to indurate. 
Induration increasing. 
Induration well marked. 



An itching red 



3d month. 



4th month. 



5th month. 



A roseolous rash; chancre very hard; bullet bubo in groin. 
Papular, scaly, or pustular eruption, sores on tonsils, and 
other secondary symptoms. 



Rash and other secondary phenomena continued and ag- 
gravated. 
Iritis or retinitis may occur. 



Secondary symptoms continued in some cases, disappearing 

in others. Chancre and bubo beginning to diminish. 
Iritis or retinitis mav occur. 



840 



DISEASES OF THE SKIN. 



Chronological Statement of Events during the First Year of 
Acquired Syphilis. No Mercury Given. — Continued. 



6th month. 



Secondary symptoms continued. 

Repeated crops of eruption. 

Chancre probably gone; in many cases, patient quite well. 



7th month. 



Secondary symptoms continued, or beginning to fade. 



8th month. 



Secondary symptoms slowly diminishing or perhaps recur- 
ring repeatedly. 



9th month. 



Patient probably well, but possibly still with rash out; lia- 
bility in certain cases to palmar syphilid, sores in throat, 
and irregular eruptions in skin. 



10th month. 



Same as ninth, but probably symptoms diminished. 



nth month. 



Symptoms still diminishing, if any. 



1 2th month. 



In majority, patient well for several months; in a few, still 
with sore throat, sores, and irregular eruptions. In ex- 
ceptional cases secondary symptoms still severe. 



The period of latency or reminders now begins, after which, 
at a very uncertain date, tertiary symptoms may follow. 



Chronological Statement of the Course of Syphilis. 



1 st year. 



Infection, indurate sore, bullet bubo, rash in two months* 
Roseolous eruption; gray-edged sore in tonsils; febrile 
disturbance; rheumatoid pains in joints; papular rash; 
possibly ulcerating iritis; sores in mouth: condylomata at 
arms, and on tongue; loss of hair. 



2d year. 



Unless severe case, probably free from exanthem symptoms. 
Perhaps superficial sores on palate and tongue; palmar 
syphilid, etc. 



3d year. 



Probably well. Rarely liable to choroiditis disseminata, and 
diseases of cerebral arteries leading to paralysis. Relapses 
of second symptoms, more especially phagedena; sores on 
skin and mouth. 



SYPHILIS. 841 

Chronological Statement of the Course of Syphilis. — Continued. 



4th year. 


Probably well. If a man has been two years free from 

symptoms, may be allowed to marry. 
Risks as in third year. 


5th year. 


Probably well. Liability to syphilitic orchitis, palmar syph- 
ilid, acne (scarring), necrosis of bones in nose, etc., is 
now perhaps at its greatest. 


6th year. 


Probably well. Same liability as in fifth year. 


7th year. 


Probably without relapse. Increased risk of gummata in 
cellular tissue, periosteum, nerves, and meninges. 


8th year. 


Large majority of patients keep welt from beginning of 
second year. His liabilities to the above maladies of the 
seventh year increase. 


9th, 10th and 
nth years. 


Perhaps increasingly liable to the events o£ seventh year. 


12th and 
onwards. 


Still and always liable to late tertiary symptoms, however 
latent the disease may have remained. 



Malignant Syphilis. — This term is often loosely applied to 
almost any severe case of syphilis, but I agree with Neisser and 
Haslund * that it should be restricted to secondary syphilis, 
where there are, as laid down by Neisser: 

Severe constitutional symptoms indicative of toxin action; 
extensive and irregularly distributed lesions of the skin and 
mucous membranes, of a pustular and ulcerative character, 
especially attacking the head and face; the ulceration being an 
early symptom, in some cases replacing the roseola, in others 
developing on deep-seated, rapidly growing, reddish-brown 
syphilomata, in either case soon reaching its limit and not 
spreading serpiginously; the evolution and disintegration of the 
lesions being very rapid. He adds pleomorphism, but that is 
a feature of all marked secondary eruptions. The lesions of the 
mucous membranes may sometimes be mild while the skin 

*At International Derm. Cong., 1896 (p. 659 of Trans.), a discussion 
was opened by Haslund, Tarnowsky, and Neisser. 



842 DISEASES OF THE SKIN. 

lesions are severe or vice versa, but more frequently destruction 
of the septum nasi and severe affections of the larynx are con- 
comitants. Hemorrhage and gangrene of the lesions, while 
they are frequent aggravating complications, do not of them- 
selves indicate malignancy, as they may also occur in otherwise 
mild forms. It is noteworthy that milder forms of eruption, 
such as typical macular and papular lesions, sometimes follow 
the ulcerative lesions; and finally, mercury must be given with 
the greatest caution, as it sometimes not only fails to heal the 
lesions, but may be actually injurious. They also do not re- 
spond to iodids like the ordinary tertiary lesions. 

Tarnowsky includes all phagedenic forms with malignant 
syphilis, and also cases which are dangerous on account of 
localization, like early cerebral syphilis, and some authors in- 
clude severe tertiary cases, especially when developing early in 
the disease; and Fournier considers the above described early 
ulcerations as evidence of precocious tertiarism, but there may 
also be nodes, caries, and early visceral lesions within a few 
weeks of infection. The cause of this malignant course is still 
in dispute, but the balance of evidence goes to show that it is 
the soil rather than the seed or the quantity of it which is at 
fault, though there may be no recognizable cachexia in the 
victim. 

Cutaneous manifestations. — Syphilitic eruptions are very nu- 
merous, and are often named after the non-specific rashes, 
which they may resemble more or less closely, e. g., syphilitic 
eczema, psoriasis, lichen, etc.; but since their clinical differences 
are greater than their resemblances, and their pathology quite 
different, this nomenclature leads to confusion, and the nature 
of the elementary lesions, whether erythema, papule, pustule, or 
bulla, as proposed by Cazenave, is the foundation of the modern 
nomenclature.* The following classification is pathological: 

I. Circumscribed hyperemia, with slight infiltration: 

Macular. Erythematous. 

II. Marked infiltration of the papillary body: 

f i. Dry papular. 

Papular, variously J 2 - Squamous, patchy, or circinate. 

modified. 1 3- Lenticular or large papule. 

L 4. Moist papular, or mucous tubercles. 

*This arrangement is slightly modified from one proposed by Sangster 
in Lancet, December 1, 1883. 



SYPHILIS. 843 

III. Especial implication of the hair follicle or its immediate neigh- 

borhood: 

Follicular, of f MiHary pa P ular ° r folUcular { !m a lT. 

progressive -I Miliary papulo-vesicular. 

severity. 1 Miliary papulo-pustular. 

(_ Acneiform. 

IV. Infiltration with subepithelial suppuration and superficial 

ulceration: 
Varicelliform and Varioliform. 

Ecthymatous. \ S , U ^ )e 

( deep. 

Bullous. jrupia 

( pemphigoid. 

V. Gummatous infiltration with tendency to ulceration: 

Nodular syphilids. 

VI. Extravasation of blood constituents: 

Pigmentary syphilid (coloring matter only). 
Purpuric (blood). 

•Deep phagedena or ulceration may occur in the primary, 
secondary, and tertiary lesions. 

General Character of Syphilids. — The secondary eruptions are 
bilateral,* and in the main symmetrical, tending to be distrib- 
uted over a wide area of the body surface; and while no part 
is exempt from them, they show some preference for particular 
regions, but never, like psoriasis, for example, affect distant 
points, leaving the rest free or nearly so. The localities chiefly 
favored are the forehead, especially where it joins the scalp 
(" corona veneris "), the lower part of the face round the 
mouth, the margins of the nostrils, the nape, the trunk, the 
flexor aspect of the limbs, especially the palms and soles, while 
the backs of the hands and feet usually escape. In their local- 
ization they often contrast with non-syphilitic eruptions, which 
they may resemble in appearance. Many of the lesions tend 
to be arranged in circles, and some others in irregular and oc- 
casionally herpetiform groups. The color is bright red at first, 
and it is often not till the eruption has been out for a few days 
that the well-known dull red tint, which is usually termed cop- 
pery, but which in most instances is of the tint of a raw ham, 

*T. Falcone records [abs. Ann. de Derm, et de Syph., vol. ix. (1888), p. 
425] a case where all the lesions, pustular, scaly, and roseolar, were 
entirely confined to the right side in a man of thirty-two. No cause was 
ascertained. 



844 DISEASES OF THE SKIN. 

is developed; later still it becomes brownish or yellowish-red, 
and ultimately stains of a more or less pronounced fawn or 
brown color are left. The lesions frequently change their ap- 
pearance, e. g., papules develop into vesicles or pustules on the 
one hand, or spread into squamous patches on the other; as 
a rule, the whole eruption does not come out at once, but 
gradually, and so it happens that all stages, from the beginning 
to the end, may be present together. Moreover, the variety of 
eruptions is as great as the number of elementary lesions to 
which the skin is liable; several of these are often associated or 
overlap one another, and, from these various circumstances, 
the important feature of " polymorphism " is produced, so that 
a polymorphous, non-pruritic eruption is almost characteristic 
of syphilis. Subjective symptoms, such as itching, burning, 
or pain, are often absent, and never conspicuous; but moderate 
itching is not uncommon when the eruption develops acutely, 
or is in warm situations like the perineum or scrotum. The 
course is, as a rule, slow, both in development and retrogres- 
sion, and they have a great tendency to recur. 

These peculiarities of symmetry, position, arrangement, color, 
variability, polymorphism, pigmentation, and absence of sub- 
jective sensations constitute a group of symptoms which, when 
taken together, enable a diagnosis to be made without further 
difficulty in most cases, but there is no more common source of 
error than that of depending upon one or two such indications, 
without taking the whole of the circumstances modifying dis- 
ease into account. Jullien advocates the inspection of the 
eruptions through cobalt blue glasses, and says that by their 
means the syphilid may be recognized at an early or late stage 
when they could not be seen by ordinary vision. 

Tertiary syphilids, as a rule, occupy only a limited area, are 
non-symmetrical, and while possessing some preference for 
such parts as the face and scalp, the palms and soles, round 
the knee, etc., the seat is often determined by some local irrita- 
tion. On the trunk they sometimes have a zosteriform distri- 
bution. 

There is, as a rule, compared with secondary eruptions, 
greater infiltration of the affected tissues, and a readiness to 
break down and produce scars, either by atrophy or ulcera- 
tion, the latter taking a circinate form. They are mono- 



SYPHILIS. 845 

morphous, of squamous or of gummatous character, possess 
but little tendency to spontaneous recovery, and are apt to 
recur, but are always very amenable to treatment. 

Pathology. — It has long been an inference that syphilis is a 
bacillary disease, and the discovery of lepra and tubercle bacilli 
has strengthened it.* Nevertheless, although micrococci or 
bacilli have been described by numerous observers in connec- 
tion with syphilitic lesions, none of them are accepted generally 
as the pathogenic agent, and the matter, therefore, is still sub 
judice. De Lisle and Jullien, in 1901, are the latest claimants 
on the following grounds: 

I. They have found the microbe in cases of active syphilis 
only. 2. The microbe agglutinates the serum of syphilitic sub- 
jects, and not of others. 3. In animals it causes special lesions 
comparable to those found in man. 4. It fixes the alexine of 
animals inoculated with syphilitic products. 5. Cultures have 
no effect on syphilitic subjects. 6. As in syphilis of man, the 
microbes die with the infected animals. . The bacillus is poly- 
morphous, varying from five to eight pi in length to an elon- 
gated filament. It is mobile, and can be colored by ordinary 
stains, but not by Gram's method. It is found in plasma and 
blister fluid, but not in the blood, owing to the presence of 
alexine, which is a bactericide, in the serum of coagulated 
blood. 

Ward suggests that the phenomena of syphilis are produced 
by the toxins of a bacillus. 

Anatomy. — The anatomy of syphilitic eruptions has been examined by 
Biesiadecki, Auspitz, Neumann, f Kaposi, Cornil, Unna, Ehrmann, myself, 
and others, with general agreement as to the results in all the main points. 

With the exception of the erythematous eruption, in which hyperemia 
with comparatively slight cell infiltration are the main changes, all 
syphilids are characterized by a dense, pretty uniform, at first circum- 
scribed, round-cell infiltration inclosing the vessels. The process affects 
primarily, and mainly, the papillary body, and later, the deeper part of 
the corium, and secondary changes involving the epidermis, and even the 
subcutaneous tissue. The raw-ham color is derived from the escape of 
blood-coloring matter of wandering or extravasated red corpuscles, 

*" Bacteriology of Syphilis," Jour, des Malad. Cut. et Syfth., July, 1901. 
Good Abs. Brit. Jour. Derm., vol. xiii. (1901), p. 441. 

f Neumann's investigations contain a review of previous work on the 
subject. See Viertelj './. Derm. u. Syph., 1885, with numerous plates. 
Unna's " Histopathology " should also be consulted. 



8 4 6 



DISEASES OF THE SKIN. 



though the bulk of the infiltration is due to plasma cells and spongioblasts 
(Krzysztalowicz); mast cells are also abundant in all syphilitic lesions. 
An important point, on which Kaposi lays much stress, is that the cells 
never organize into connective tissue, but undergo retrogression, and dis- 
appear either by absorption or suppuration. This retrogression always 
commences in the center or oldest part (Virchow denies this) even, 
though, at the periphery, fresh infiltration may be simultaneously taking 
place; hence the circinate form so often assumed, especially in the later 
lesions. 

A papule is at once the type and starting-point of Jail other lesions; a 
large papule or a nodule is only an extension of the process that produced 
a small one; a slight increase in intensity will produce more fluid exudation 
in the epidermis, which is raised up, and a vesicle is formed on the papule 
as a base, or, if the intensity is greater still, a pustule is developed, 
AVhen the lesion is large, or the cell exudation very closely packed, as in 
gummatous infiltration of the skin, the vascularization of the mass is 
obstructed, and it disintegrates, breaks down, and an ulcer is produced! 
but in the early eruptions the connective and elastic tissues are dissociated 
but not destroyed. Giant cells have been found in gummata, and also in 
nodular, follicular, and acneiform syphilids. 

An important practical point, established by Neumann's observations, 
and amply confirmed by Hjelmman,* is that the diseased products, mainly 
exudation cells, persist in the tissues, though in diminished quantity, for 
from four to eight months at least after the disappearance of the clinical 
symptoms. The cells, which may be spindle-shaped and pigmented, 
affect chiefly the vessel walls, hair follicles, sebaceous glands, and sweat 
ducts, but the upper cutis layer may also be infiltrated, and perhaps 
granularly clouded. There may also be thickening of the vessel walls 
and follicles. It is not possible to say how long these products persist, 
but their observations lend a strong support to Hutchinson's doctrine " of 
residues of the early period of syphilis, being the starting-point of later 
lesions." With regard to pigmentation, when that affects the exudation 
cells only, the duration is comparatively short, but where the connective- 
tissue cells are pigmented the duration is very long, and may be permanent. 

Justus and Konried have shown that there is a great fall in hemoglobin, 
commencing when general adenitis is established, and becoming lowest 
when secondary manifestations occur. This may be restored by mercury, 
but the blood also tends to recover spontaneously. 

The Erythematous or Macular Syphilid, Syphilitic Roseola 
or Exanthem (Plate I., Fig. i) is the earliest of the skin mani- 
festations; it is very rarely absent, but, being often inconspicu- 



* This observer found that cell infiltration was still present from half to 
three years after the hard sore was macroscopically healed, that in roseola 
it only lasted a month, and in dry papular syphilids it lasted six months, 
and in moist papules twelve months. Archiv f. Derm. u. Syfth., vol. 
xlv. (1898), p. 57- 



Plate I. 



lTe //. 



SYPHILIDES. 



SYPHILIDES. 



Fig. 2. Papulo-Squ 



sJ^ 






Fig. 4. Large Fo 




Fi 8-9- Rupia 



Fig. 6. Papulo-Pustular. 




Fig. 7. Large Papular or Lenticular. 



Fig. 8. Corymbose. 




'v. 



Fig. 10. Tubercula 



Fig. II. Pigmentary. 



Fig. 12. Late Squamous of Pain 



r 



SYPHILIS. 7 847 

ous, or mingled with other eruptions, and unattended by sub- 
jective symptoms, may be overlooked by the patient; It usually 
comes out six or seven weeks from the first appearance of the 
initial lesion, taking, as a rule, a week or ten days for its full 
development, but may break out acutely in a single day, if con- 
gestion of the capillaries of the skin is produced by violent ex- 
ertion, hot baths, or alcoholic excess, and there may be slight 
heat and itching. It may appear as a diffused mottling or mar- 
bling of the skin, very like that often seen % on covered parts, 
when exposed to the air, in spots the size of the finger tip, or 
as small as one-eighth of an inch in diameter, with ill-defined 
and irregular borders. In a few cases the "lesions are raised up 
like a pink wheal, but without itching, "1 tfrfe wheal type " as it 
has been called. They evolute gradually,* persist for weeks, 
and leave stains, and there is seldom any itching. The color is 
a bright rose pink at first, completely removable by pressure, 
but very soon it gets duller, or even purplish in hue, and after 
pressure there is still a yellowish tint; ultimately the macula 
fades into a dirty yellowish or grayish-brown stain, which re- 
mains long after the exanthem itself has gone, but there is 
seldom desquamation. The favorite localities are the front of 
the trunk, especially the chest and epigastrium, the flank, the 
back, less commonly the upper segment of the limbs, or the 
wrists, somewhat more upon the flexor than the extensor as- 
pect. Occasionally it is very widely spread over the body sur- 
face, but even then the face often escapes, or it only affects the 
forehead and round the mouth. In rare instances it begins on 
the face. Febrile, and some of the other symptoms mentioned, 
generally precede the eruption, and it is seldom indeed not to 
find corroborative symptoms, such as redness or ulceration of 
the fauces, gland enlargements, bone-pains, etc. In five cases 
out of six (Bassereau), other forms of eruption also, chiefly the 
papular, will be present, and prevent error in diagnosis which 
might arise, especially with the papular rashes of measles, 

*Klotz read a paper with references on this " wheal type" in which the 
resemblance is only in form. Amer. Derm. Assoc. Trans., 1900, p. 159- 
I have met with cases in which, in the first six months of syphilis, 
brownish-red wheals came out suddenly, lasted several hours to a day or 
two, did not itch, and left faint stains. Slight but distinct urticaria 
factitia was present, and there was constipation. This was therefore an 
urticaria in the course of syphilis, and not a syphilid. 



848 DISEASES OF THE SKIN. 

rotheln, urticaria with pink wheals, various erythematous erup- 
tions, idiopathic, symptomatic, or medicinal, if regard be had 
to the skin lesions alone. The position on the trunk, while the 
face, the backs of the hands, and wrists, which are favorite posi- 
tions for most erythemata, are free; the absence of itching, 
and later on the stains, are further important aids. Tinea 
versicolor can only be mistaken by a careless observer, for the 
stains of the macular and other syphilids are in, and not on 
the skin. 

The duration varies from one to four weeks, but slight re- 
lapses of limited duration, chiefly on the forehead and chest, 
sometimes occur in the first year, and a smaller or circinate 
form may occasionally appear in the second or third year of 
disease. 

Tertiary circinate erythema (Neuro-syphilid of Unna). — 
Fournier * has drawn attention to a late syphilitic roseola, con- 
sisting of rounded, oval, or irregular, very superficial rings or 
patches of a rose color at first, later getting a brownish-red 
tint, paling on pressure; the patches tend also to clear in the 
center, while fine branny scales cover the peripheral portion. 
It is rare,f often unassociated with other tertiary symptoms, 
responds very slightly to internal treatment, and shows a great 
tendency to recur. I have seen it as a late secondary. Etienne 
met with it at an early period with other secondary eruptions. 
The rings are few in number as a rule, may be several inches 
in diameter, and seem to be analogues of those seen in leprosy. 

Anatomy. — The anatomy of the ordinary macula has been investigated 
by Biesiadecki, Kaposi, Neumann, and myself. The result of my investi- 
gation is as follows: The change is limited almost entirely to the upper 
layers of the corium, mainly the papillary, in a rather sharply defined 
area. The epidermis is raised up as a whole, but the cells of the horny 
layers and rete are normal as a rule, except where the effusion is greatest 
and stretches them. Here there maybe some elongation of the lowest 
cells, which may even be so disturbed that the denned line at the junction 
of the epidermis and papillary layer is lost, the papillae are more or less 

* Fournier, Annates de Derm, et de Syfik., vol. vii. (1896), p. 1141, is 
one of his most recent papers on the subject. 

f Nielsen denies this, having seen twenty-four cases, chiefly in a hospital 
for prostitutes, Copenhagen, but most people agree with Fournier. 
Monatsh.f. Derm., vol. xxii. (1896), pp. 500 and 555. Abs. Brit. Jour. 
Derm., vol. ix. (1897), p. 86. There is a model of this lesion, Mus. of Coll. 
of Surg., No. 204, Dermat. Catalogue. 



SYPHILIS. 849 

flattened out, the fibers of the corium are separated, presumably by the 
fluid effused, so that the individual fibers can be made out. The contrast 
between the upper part of the corium, with its separated fibers, and the 
normal corium below, is very distinct, but there is only moderate leuko- 
cytic infiltration, and this is almost exclusively round the vessels of the 
superficial plexus with their papillary branches; the capillaries and small 
arteries are moderately dilated, and both stuffed and surrounded with 
cells; in the walls of the capillaries are prominent nuclei, and there are 
round and spindle cells in the adventitia of the larger vessels, as was first 
described by Biesiadecki. There is a slight cell effusion round the hair 
and sebaceous follicles, and sweat ducts, where they lie in the upper part 
of the corium, but the sweat glands, and all the structures in the deep 
part of the corium, are normal. Kaposi saw caudate cells in the connec- 
tive tissue of the papillae— indicative, he thinks, of proliferation of the 
connective-tissue cells; and Neumann affirms that the change goes right 




—Part of a syphilitic macula. X 125. 

a, connective-tissue bands of the corium separated by the cell effusion, 
b, &, which is chiefly in foci in the course of the vessels. In the upper 
part of the corium the individual fibers are separated by the inflam- 
matory effusion, and the papillae are flattened out. c, normal 
epidermis. 

down to the fat, but this was certainly not the case in the macula I 
examined. As all the structures of the skin in his case appear to have 
been more affected, especially the hair-sacs, muscles, sebaceous and sweat 
glands, than in the cases of Biesiadecki, Kaposi, and myself . possibly his 
patch was of longer duration. Neumann also observed granular pigment 
in the upper part of the corium, but only in the exudation cells. 

Papular Syphilids are of two classes, according to whether 
they are formed round a hair follicle or independently of it. 
The non-follicular are formed by the papillary infiltration rais- 
ing up the epidermis, and are flat or lenticular, and of two 

54 



850 DISEASES OF THE SKIN. 

varieties, large and small. The follicular are situated round the 
mouth of a hair follicle, are conical, and are often termed 
miliary or lichenoid. Here also there are two varieties, large 
and small. The small flat papular syphilid is a mixture of 
papules and scaly patches; it is best known as the papulo- 
squamous syphilid, and the circinate scaly syphilid is a variety 
of it. 

The large, flat papular syphilid has large, disseminate 
papules, not scaly as a rule, and is especially, from its shape, 
entitled to the term " lenticular," though that name is by some 
authors made to include both forms, and is used by B. Hill for 
the small flat papules in the scaly collar stage. 

Syphiloderma Papulo-squamosum (Plate L, Fig. 2). Syno- 
nyms. — Small, flat, papular, nummular, or squamous syphilid; 
Syphilitic psoriasis. 

This is seen at any period of the first, and occasionally in the 
second year of the disease, and is one of the commonest of the 
syphilids. According to the stage of the eruption, one or other 
of the above names is applicable. Commencing as a small,, 
bright red, flat papule, it extends peripherally, and desquamates 
at the apex; when this scaly cap is thrown off a characteristic 
collar of loosened scales is formed from a quarter to three- 
quarters of an inch in diameter, seldom larger, and according 
to the age of the patch, of a bright or dull brownish-red or 
yellowish-brown color, or, on the legs, occasionally purplish- 
red. The scales are usually scanty and dirty-looking, but some- 
times rather abundant and silvery, but never so much as in true 
psoriasis. This scaly eruption is the stage most frequently- 
brought under notice, to which the terms nummular and 
squamous are suitably and psoriasis erroneously applied. The 
eruption usually comes out in crops, and while, as a whole, it 
may last for months if untreated, many of the patches undergo 
spontaneous involution, leaving fawn-colored stains, and all 
stages of the eruption may thus be present together and form 
a very characteristic picture. The distribution is often very ex- 
tensive. No part is exempt from liability to it; it is often all 
over the trunk and limbs, predominating on the flexor aspects, 
on the face, especially on the forehead, at the margin of the 
hairy scalp (corona veneris), and on the lower part, round the 



SYPHILIS. 



851 



mouth and nose. Occasionally it forms herpetiform groups, 
even unilaterally. The patches, as a rule, though often closely 
set, remain discrete, but may coalesce in parts like the lower 
part of the face, round the perineum or genitals, etc., but these 
areas will still present traces of the constituent patches (en nappe 
aspect of French authors). Slight itching is not uncommon at 
first, but it is never a very prominent symptom. 

Diagnosis. — It is distinguished from most cases of psoriasis 
by its predominance on the flexor aspect of the limbs, and by 




Fig. 48. — Papulosquamous syphilid from the bend of elbow. X 125. 
a, enlarged papilla, free-cell exudation separating connective-tissue 
fibers; b, exudation-cell masses round vessels ; c, similar cell masses 
round a hair follicle and in wedge-shaped foci in the deep part of the 
corium. The epidermis is thickened with downgrowth of the inter- 
papillary part. The greater part of the scales has fallen off in the 
preparation. 

the uniform small size of the patches; but these criteria fail for 
guttate psoriasis, from which it may be distinguished by atten- 
tion to the following points: The syphilid is most common on 
the flexor aspect of the limbs; there are never widely distant 
foci of disease with healthy skin intervening; the patches are 
pretty uniform in size, and distinctly raised above the surface; 
the scales are usually scanty and dirty-looking and easily de- 
tached, and are never abundant enough to conceal the color of 
the patch, which is of a duller red than that of psoriasis; brown- 
ish stains are left, and are often intermingled with more recent 
scaly patches; there are no bleeding or red points when the 



852 DISEASES OF THE SKIN. 

scales are removed; the palms and soles are often attacked; itch- 
ing is slight or absent, and other forms of eruption, or at least, 
other symptoms of syphilis, are sure to be present. In psoriasis, 
the eruption is mainly on the extensor aspect, at widely distant 
points, e. g., elbow, knee, and scalp; the scales are abundant, 
silvery, and firmly adherent, concealing the bright red patch, and 
when removed, bright red or bleeding points are visible; there 
is little or no staining left after the eruption, except when 
arsenic has been given, when the brownish staining of a syphilid 
may be imitated; and the general health is usually unaffected. 
The cachexia, the absence or slight degree of itching, and the 
early desquamation, with little, if any, tendency to vesiculation, 
distinguished the early papular stage from papular eczema. 

Anatomy. — I found the following changes in a squamous plaque (Fig. 
48) a quarter of an inch in diameter, removed from the bend of the elbow 
of a man who had had a chancre three months previously. 

The upper half of the horny layers had desquamated, the rete was 
thinned in some places and thickened in others ; the thinned part was 
where the process was most acute; the outline of the lowest part of the 
rete was irregular from loosening of the lowest cells, which were verti- 
cally elongated, but attenuated. Where the rete cells had proliferated 
and the whole become thickened, the sharp definition of the boundary 
line between the rete and papillae was preserved, and the rete processes 
were broader, as well as elongated. 

In the more acute part the papillae were enlarged laterally and verti- 
cally, the fibrous structure was obscuted with amorphous granules, and 
the round cells present in only moderate numbers; the effusion of serum 
and leukocytes was greatest in the papillae, getting gradually less toward 
the horizontal plexus, but not ceasing there entirely. Here and there 
small collections of round cells were to be seen deep in the corium, e. g., 
round a vessel communicating with the deep and superficial plexuses, be- 
tween the acini of a sweat gland, or round the base of a hair follicle, 
though these structures were not as a rule affected in their deep part. 
Then it was common enough to see cell infiltration between the angle of 
the rete, and a hair follicle or sweat duct, sometimes on one side only, 
pushing the hair over almost parallel to its arrector muscle, whilst, when 
on both sides, it often extended downward for a considerable distance. 

Syphiloderma Circinatum (Plate II., Fig. 3). Synonyms. — 
Circinate, orbicular, or annular syphilid, or lepra syphilitica of 
old authors. This is another form of squamous eruption of the 
secondary period, but is much less common, and usually later 
than the small patch form, of which it may be the relapsing 
representative in the second year, or even several years after 



SYPHILIS. 853 

infection; but its most common period is in the first five or six 
months to the end of the first year of disease, and it may be quite 
early. It may appear upon any part of the body or head, but the 
favorite positions are the nape and other parts of the neck, fore- 
head, and round the mouth and chin. In form it is in circles 
from half an inch to an inch in diameter, or, by coalescence of 
two or more rings, in gyrate figures with clear centers and 
sharply defined, distinctly raised borders, about an eighth of 
an inch wide, dull, or yellowish-red after the first few days, and 
moderately scaly as a rule, but sometimes crusted with silvery 
scales, and, except for its position, very like the ringed forms 
of psoriasis. The distinctions are the same as those already 
mentioned in small patch syphilids, especially the cachexia, to- 
gether with the presence of the eruption in parts where psoriasis 
is seldom seen. The occipital glands are almost always notably 
enlarged. Both this and the nummular form relapse more fre- 
quently than the follicular syphilids; but, as a rule, the older 
the disease the less extensive is the rash. 

This form especially, in Unna's view, is the outcome of a com- 
bination of the seborrheic process and syphilis — a combination 
which he considers is very common, and exercises an important 
influence in determining the character and position of so many 
syphilitic eruptions. That syphilis predisposes to seborrhea 
capitis has long been recognized, but few go so far as Unna in 
acknowledging the converse influence in so many syphilids. 

On the palms and soles the appearance of the eruption is con- 
siderably modified by the anatomical peculiarities of these parts, 
and is often called psoriasis palmaris or plantaris. In the sec- 
ondary period it is usually symmetrical, generally occurs in the 
second year of the disease, but may be quite early in the first 
year; when very early, it is the more likely to form only part 
of the general eruption, or to be associated with other dis- 
tinctive symptoms. 

It begins as a coppery-red spot, seen through the translucent 
epidermis, but not always perceptible to the touch; the epi- 
dermis over it first thickens, gets opaque, gives way, and forms 
irregular cracks, and has a worm-eaten aspect, or is thrown off 
en masse, without splitting up into lamellae, and leaves a tender 
area below the general surface inclosed by a jagged collar of 
epidermis; or fissures may form in the course of the natural deep 



854 DISEASES OF THE SKIN. 

lines of the palm, which are sure to follow their direction, and 
often go quite down to the corium. A somewhat similar 
squamous eruption may be seen in the tertiary period, often 
constituting the sole manifestation of the disease, after perhaps 
many years of freedom from the symptoms, and this in married 
women who have never shown any previous specific symptoms. 
Being often determined by local irritants, it is very likely to be 
unilateral, and is most common in those who have to do manual 
labor. It almost invariably begins in the center of the palm, 
consists chiefly of thickened epidermis, which readily splits into 
deep, painful fissures, chiefly following the direction of the 
natural folds. On the foot it is often associated with papillary 
hypertrophy. 

Diagnosis is seldom difficult. In the secondary period the 
presence of other characteristic eruptions and symptoms, and 
its symmetry and amenability to specific treatment, would re- 
move all doubt; but some of the circinate seborrheic eczema- 
form eruptions at the hair borders front and back, and on the 
face, rather closely resemble the orbicular syphilid. There 
would always be abundant seborrhea with or without accom- 
panying inflammation, and of course the other symptoms of 
syphilis would be absent. These criteria hold good when the 
syphilid is present as a late secondary eruption, but when all 
other specific symptoms have long ceased to trouble the patient, 
and the remembrance even of his old enemy has faded away, 
neither the diagnosis nor treatment is easy. Eczema palmare 
is often very like it. Here, too, there are great thickening of 
the epidermis and deep, painful fissures ; but while the syphilid 
nearly always begins in the center of the palm, eczema 'rarely 
does so, being generally at the wrist or root of the thumb, and 
reaching the palm later. Simple psoriasis is rare on the palms 
or soles, and very rare without the typical eruption elsewhere; 
there is less thickening or Assuring, and no special tendency to 
begin in the center of the palm. 

Anatomy. — In the border of a circinate syphilid (Fig. 49), on the tip 
of the elbow, which came about six months after the chancre, and in 
which there was free scaling very like psoriasis, there was great increase 
of the horny layers, which were almost completely thrown off, in many 
of the sections leaving only a few lamellae still attached to the rete. 
There was also an increase in the thickness of the stratum granulosum. 



SYPHILIS. 



855 



The upper part of the scaly crust was homogeneous with closely com- 
pressed layers, but the deeper portion was of looser structure, and in the 
picro-carmine sections could be seen to be permeated with minute 
rounded bodies both scattered and in masses, which stained with car- 
mine and contrasted sharply with the yellow picric-acid-stained horny 
layers. In the rete there was marked proliferation of its cells, and not 
only was it thickened, as a whole, but the interpapillary processes were 




Fig. 49. — Circinate squamous syphilid. X 125. 

a, horny layers forming scales ; b, oblique section of an enlarged papilla 
in the greatly thickened rete mucosum ; c, enormously enlarged 
papilla with cell exudation separating its fibers; d, dense round cell 
exudation in masses round the vessels; e, similar cell exudation 
round a vessel of the deep plexus. There is also a scanty cell effusion 
all through the corium. 

greatly elongated, and sometimes interlaced, forming lacunae filled with 
leukocytes. 

The papillae were correspondingly enlarged, both vertically and later- 
ally, to from four to five times the size of the normal; they were filled 
with exudation cells, which extended to the horizontal vessels of the 
superficial plexus, in diminishing numbers, but very few leukocytes ex- 
tended into the rete. The capillaries were greatly dilated, but there 
was not much infiltration of their walls. The deep layers of the corium 
were only slightly involved, there being only here and there slight effusion 
round the vessels. When the sweat ducts passed through the infiltration, 
there was proliferation of their cells and blocking of the lumen, but the 



856 DISEASES OF THE SKIN. 

deeper parts were not always affected, though in some sweat coils there 
was cell infiltration between and proliferation within the coils. The 
hair follicles and their appendages escaped altogether, or with trifling 
cell infiltration round them. Clearly this is a different condition to what 
Neumann calls papulae syphiliticae orbiculares, in which he describes the 
hair follicles and their belongings as the center and acme of the process. 

Large Papular Syphilid (Plate II., Fig. 7). Synonym. — 
Lenticular syphilid. This is one of the common early eruptions 
often following closely upon or mixed up with the erythematous 
lesion. It may, however, be one of the relapsing manifestations 
at a late period. The papules may be widely spread and nu- 
merous, but not closely packed; or they may be few and local- 
ized, but do not often group, except round the mouth or genitals. 
The most common positions are on the forehead, lower part 
of the face, nape, and trunk, especially the back, the flexor 
aspect of the limbs, and about the genito-anal passages of both 
sexes. The lesions are from an eighth to half an inch in 
diameter, distinctly raised, sharply defined, flatly convex, vary- 
ing much in color, and, as a rule, of a deep red or raw-ham tint, 
but sometimes pale, and at other times a purplish-red, firm and 
smooth to the touch, though after a time they may desquamate. 
The larger ones are nodules rather than papules. These may 
be combined with the large follicular syphilid in a way to be 
presently described. 

The diagnosis is easy, both from the fact that other syphilids 
and symptoms are likely to be present, and because the large 
papules are practically diagnostic, being simulated only by the 
nodules of leprosy, in which the history of residence in a leprous 
district and the general symptoms of that disease would be 
decisive, but when the two diseases are associated, the diag- 
nosis may be no easy matter, unless, as in one instance that 
came under my notice, anesthesia were present, which is not 
always the case in tuberculated leprosy. A careful analysis of 
the history would be necessary in such cases. 

Anatomy. — In the large papule (Fig. 50), the cell infiltration affects the 
whole of the corium, commencing round the vessels of the superficial and 
deep plexuses, and their various ramifications. The cell effusion is 
usually greater in the papillary layer and the parts subjacent, so that 
here the structure of the corium is completely replaced or obscured by it, 
and the vessels appear in places as if they were mere channels in the 
cell effusion; in other parts they are only indicated by the position and 



SYPHILIS. 



857 



arrangement of the cell masses; this is very noticeable in the vessels of 
the hair follicles and sweat ducts. There is, however, but little cell 
infiltration of the hair follicle itself, and its outline is not altered as a 
rule, but the fibers of the arrector pili muscles are often separated by- 
leukocytes. Both in the sweat ducts and coils the lumen was often 
blocked by proliferation of the lining cells, and sometimes the structure 
was destroyed. There was always more or less cell infiltration between 
the coils, in places quite obscuring the gland structure; the rete was 
stretched and thinned in some places, slightly thickened in others, and 
occasionally there was downgrowth of the interpapillary processes. The 
outline of the palisade layer was generally well defined, and there was 
but little leukocytic infiltration, while there was occasionally slight 
loosening of the upper part of the horny layer, which was otherwise 
unaffected. 

Follicular Syphilids. There is a large and small form of this 
variety of papular syphilid, in which the hair follicle is the 
seat of the lesion, constituting the so-called " syphilitic lichen or 




Fig. 50. — Lenticular syphilid. 2-in. obj., 2-in. ocul. 

a, normal epidermis; 6, dense cell masses round the blood-vessels in the 
deep part of the corium, and uniformly diffused through the papillary 
layer. 

miliary syphilid." The larger is not a very common eruption 
(Plate II., Fig. 4), but much more so than the small form. It 
generally occurs in the first six months of disease, and its most 
distinctive feature is its occurrence in irregular groups of three 
or four up to twenty or more. The most common positions 
are the extensor aspect of the limbs and the back, but it is not 
unusual to find it on the neck and breast, and it may be widely 
spread. The papules are about the size of a large pin's head 



8 5 8 



DISEASES OF THE SKIN. 



or millet seed, bright red at first, but soon changing to brownish- 
red, and becoming crowned with a small scale, which is some- 
times the remains of a minute vesicle. When they involute, they 
become flattened, and even depressed below the surface, leav- 
ing a pigmented pit. The eruption comes out in crops, so that 
all stages may be present simultaneously; occasionally the in- 




Fig. 51. — Larger follicular syphilid. X 125. 

a, cell effusion in the angle of the hair follicle; b, dilated hair sac nearly 
filled with horny scales ; c, hair papilla destroyed by the inflamma- 
tion; d, inflammatory effusion separating hair sac from the hair itself; 
e, portion of dilated hair sac;/, masses of cell effusion below the 
hair follicle. 

flammation is intense enough to form vesicles or even pustules 
on the apex of some or all of the papules. Groups of brownish- 
red papules on the limbs and trunk, leaving pigmented and often 
atrophic pits, are very distinctive, and should always suggest 
further inquiry for the evidence of syphilis, which is invariably 
forthcoming at this stage. 

Anatomy. — The examination of the papules in the larger follicular 
syphilid (Fig. 51) showed that the whole process was in and around the 
hair follicle, but, unlike the non-specific lichen, the inflammation affected 
the hair papilla itself, whereas in all other lichens, the inflammation is 



SYPHILIS. 859 

limited to the angles of the follicles and rete, and immediately round the 

external sheath, and any changes in the follicle, such as the knoblike 
outgrowths described by Xeumann in lichen ruber, pityriasis, etc., were 
secondary and only occurred in cases of long standing. There was slight 
disturbance in the horny layers adjacent to the hair follicle, and the 
rete was thickened and raised up by the effusion beneath, so as to form a 
papule round the hair. Three or four papillae adjacent to the follicle 
were broadened and slightly deepened by rete downgrowth, and there 
was dense cell infiltration, not only into the papillae, but into all the tissue 
round the follicle for its whole depth; this cell infiltration did not, how- 
ever, extend far from the follicle in a horizontal direction, but its boun- 
daries were not abruptly defined. Vertically, it went down directly 
below the follicle, but either did not extend to the fat, or did so only by 
the narrow columnae that Warren has described. Where the cell infiltra- 
tion was greatest, the structure of the corium was quite obliterated, the 
vessels of the papillae were dilated, and their walls studded with nuclei, the 
position of the larger vessels being only indicated by a well-defined mass 
of densely crowded cells which entirely concealed the vessel wall, and 
evidently both filled and surrounded the lumen. Coming to the follicle 
itself, the lower part of the external root-sheath below the hair shaft was 
dilated into a circular sac, which was ruptured at the lowest part, where 
the pressure was greatest; it had evidently been filled with cells, though 
in the section drawn it may be seen that many have fallen out in its 
preparation (Fig. 51). The internal root sheath was also ruptured by 
similar distention, and the papillae were densely infiltrated with leuko- 
cytes, which had partially separated the shaft from the inner sheath; in 
some hair follicles there was inflammation round them, but the hair 
papilla was untouched. The sebaceous glands were similarly involved 
in the process, their elements being either separated or else only a frag- 
ment of the gland left, but the arrector pili muscle was not involved at 
this stage. In the sweat glands, which were near the affected hair 
follicle, there was cell infiltration between the coils and epithelial pro- 
liferation within them, but those further off were normal. 

In a papule undergoing involution, which was removed from the 
flexor surface of the forearm of a woman, set. thirty-two, in whom the 
eruption had commenced three months previously, preceded for about 
three weeks by the usual premonitory symptoms, the papule was not 
formed about the hair follicle, but by the lifting up of the epidermis by 
dense cell effusion, in the center of which a sweat duct could sometimes 
be traced. The effusion obscured or destroyed the corium structure 
where the effusion was greatest, only fragments of it and its vessels 
being discernible. The mass of it was pretty sharply defined below. 
where it was bounded by the upper wall of the vessels of the superficial 
plexus. The rest of the corium was normal except in the immediate 
neighborhood of the vessels, whose position was marked by a defined 
oval or round mass of leukocytes, but the vessel walls were invisible. In 
the epidermis the most superficial part of the horny layers had des- 
quamated, and the rete cells, especially the lowest, were elongated and 



86o 



DISEASES OF THE SKIN. 



narrowed, giving a feathery appearance to the lower border, and some 
of the interpapillary processes were enlarged. Unstained sections 
showed that there was marked pigment deposit in the lowest cell layers. 
Similar conditions existed on each side of the papule, but where the 
process was not so advanced there was dense infiltration in the papillary 
layer only, and below that it was only round the vessels, forming 
sharply defined branched cell masses, with the bundles of the corium 




Fig. 52. — Small follicular syphilid. X 125. 
a, a, masses of round cell effusion completely inclosing the hair follicle; 
b, hair follicle unaffected; c, sweat coil with cell exudation between 
the acini. 

almost natural except from compression, filling up the intervals betweer 
them. The hair follicles were very small, most of them cut transversely, 
and there was cell infiltration round the follicles and between the fibers 
of the arrector pili, but no change in the follicle itself. Wherever there 
were sweat ducts, there was cell effusion round them, dense above, and 
blocking the lumen, but diminishing lower down and almost ceasing 
about midway down the corium; in some of the sweat coils there was 
cell infiltration between the acini and cell proliferation within them, 
while others were quite healthy. 

The above observations go to show that the papule may be formed 
round a hair follicle or sweat duct, according to the anatomy of the part 
attacked. 



SYPHILIS. 86 1 

The " small follicular syphilid " (Plate L, Fig. 5) is a rare 
manifestation of syphilis in my experience, and is more common 
in women; indeed, nearly all my cases were females. It may 
occur in the first or second year of disease, and, as far as the 
individual papules and their grouping are concerned, exactly 
resembles lichen scrofulosus, consisting of convex papules the 
size of a large or small pin's head, pink at first, but soon becom- 
ing fawn color, or even the same as the normal skin. They are 
generally thickly crowded together in groups, which may be 
irregular, roundish, or even in rings, often quite general in their 
distribution. This eruption is very persistent unless persever- 
ingly treated, and the papules, on involution, leave minute fawn- 
colored stains behind. Like its prototype, lichen scrofulosus, 
each papule may be the seat of a central horny spine just as in 
lichen spinulosus. 

Diagnosis. — It has to be distinguished from lichen scrofulosus; 
the characters of the rash are identical in both, but while lichen 
scrofulosus is rare after puberty, and never later than thirty, 
the syphilid may occur at any age. Lichen scrofulosus is seldom 
seen on the limbs, and never on the head, while the syphilid is 
likely to be present in both these positions. The two conditions, 
the presence of this rash in a person over twenty,* and its being 
on the limbs or head, should excite suspicion, and further in- 
quiry will nearly always furnish evidence of past or present 
syphilitic lesions. 

The miliary papulo-vesicular, the miliary papulo-pustular, and 
the acneiform syphilids may be regarded as merely develop- 
ments of the miliary papular syphilid, the inflammatory effusion 
being sufficient to produce vesicles or pustules on the papular 
foundation. 

In the small follicular syphilid (Fig. 52) there was a dense cell infiltra- 
tion completely surrounding and permeating the follicular wall, but not 
affecting the root sheaths or breaking up the structure of the follicle. 
The cell infiltration was greater at the bottom than at the angles of the 
follicle: it was very marked round the adjacent vessels, but existed in 
only a slight degree between the coils of a neighboring sweat gland. 

The horny cells round the hair shaft were increased in number, so that 
in the section, they imparted to the hair the appearance of a quill pen. 

* I saw once a well-marked example in a girl of twelve, with accidentally 
acquired syphilis. The disease had been present about two months, the 
eruption three weeks. There was no difficulty in diagnosis, as the other 
symptoms of syphilis were well-marked. 



862 DISEASES OF THE SKIN. 

Corymbose Syphilid * (Plate II., Fig. 8). This is a rare form 
in which a large lenticular papule is in the center of an irregular 
group of the large follicular papules, the compound group being 
an inch or more in diameter. This eruption may extend all over 
the trunk, or be sparsely scattered about, but I have never seen 
it on the limbs or face. As a whole it forms a striking and un- 
mistakable picture. The term is also loosely applied by some 
authors to other grouped syphilids. Whitfield suggests that 
this peculiar pattern of the eruption is because " there has been 
sufficiently strong development in the original papules to enable 
local metastasis to take place around them, such as is not unfre- 
quently seen around malignant tumors." 

The Vesicular and Pustular Syphilids. Although these tend 
to run on from one to the other, and are often present simultane- 
ously, they can be more clearly described by considering them 
separately. They vary much in their size and grouping, and so 
present some similarities to eczema, herpes, varicella or variola 
(early stage), and pemphigus, in the vesicular forms; and acne,, 
variola (late stage), and impetigo or ecthyma, in the pustular 
forms. It must not, however, be inferred that they are really 
those diseases modified by syphilis, and qualifying terms founded 
on these resemblances are better avoided. 

The foundation of nearly all these eruptions is a papule of the 
character already described, with the addition sometimes of a red 
areola. Upon this papule the vesicle or small pustule (Plate I., 
Fig. 6) develops; in some, the vesicle passes into a pustule, while 
in others the pus is present from first to last. Each lesion is 
of short duration, a few days as a rule, and then ruptures or 
dries up into a scale or crust; the scale soon falls off, and leaves 
the fiat, deep red papule, and this dies down, and a pigmented 
spot is left. The crust, which ensues on the pustule, takes 
longer to separate, ulceration often goes on beneath it, and ulti- 
mately a pigmented depression or scar is left. The eruption 
generally comes in crops, and so as a whole may last for weeks 
or months. 

*The figure in Plate II. is drawn from a case of Dr. Whitfield's, which 
he published in Brit. Jour. Derm., vol. xiii. (iqoi), p. 283, with histology. 
The cell infiltration was chiefly round the hair follicles, but involving the 
sweat glands also. There is a good model of a marked case in the 
Museum of the Roy. Coll. Surgeons, No. 185, Dermatological Series. 



SYPHILIS. 863 

Vesicular Syphilids are much less common than pustular, are 
all early eruptions, and are all very rare after the first six 
months of the disease. They run a slower course, leave stains, 
and are almost invariably associated with other symptoms or 
eruptions of syphilis. 

The Small Vesicular Eczematous Syphilid of Bassereau and 
Hardy, who first described it, is very rare. It comes out in 
crops, of small, flat, slightly raised vesicles, each seated on a 
papule surrounded by a brownish-red surface, if they are 
grouped, or with an areola round each, if scattered. They do 
not enlarge much nor do they burst and weep like true eczema, 
but after four or five weeks dry up; and the red areola having 
faded, only the deep red, flat papule is left, and this slowly dies 
down into a dirty brown stain. In exceptional cases the vesicles 
become pustules, which dry into thick scabs, and conceal super- 
ficial ulcers. Their slow progress, their trifling degree of itch- 
ing and burning compared with eczema, the absence of dis- 
charge, and the subsequent pigment, apart even from other signs 
of syphilis, mark differences much greater than the resemblances 
to eczema. 

The Large Vesicular Syphilids are grouped or herpetiform, 
and if general, varicelliform, or varioliform. In the grouped 
large vesicular, or herpetiform syphilid, the groups may be ir- 
regular, circinate, or serpiginous by coalescence; in all, the vesi- 
cles are on a deep red base, which subsequently gets brownish. 
After lasting about a week the vesicles rupture or dry up, leav- 
ing fine scales over the brownish raised base, the latter being 
rather persistent, but ultimately leaving only a stain, or, if the 
vesicle gets converted into a pustule, a thick yellow crust forms 
over it, with perhaps superficial ulceration beneath. The erup- 
tion may come on the face, limbs, or trunk, and is usually only 
in a few patches ; it differs from true herpes by the groups being 
symmetrical, slow in development and course, by the vesicles 
being seated on a raw-ham-colored base, perhaps also by the 
crusts and ulceration, by the subsequent stains, and by the pres- 
ence of other symptoms of syphilis. Hutchinson also has de- 
scribed an eruption indistinguishable from herpes zoster, except 
that it is symmetrically distributed, that it is seldom limited to 
the chest, and that it is more persistent than the non-specific 



864 DISEASES OF THE SKIN. 

form. I have seen similar cases, one a young man who had a 
patch under each scapula late in the disease. Herpetiform 
grouping of tertiary lesions is occasionally seen. 

In the varicelliform syphilid, the vesicles are either convex 
or umbilicated, and the contents soon become cloudy; they are 
situated on a slightly raised plateau, of the usual dull red color, 
and after a few days the vesicles dry into thick adherent crusts 
of a greenish-black color; when they fall off the brownish base 
is left, but it, too, soon gives place to a stained depression. 

Its occurrence in an adult, its slow course, the vesicles being 
seated on papules, more closely grouped, with more crusting 
and even ulceration, slower development and greater persistence, 
to say nothing of the presence of other symptoms of syphilis, 
distinguished it from varicella. 

The varioliform syphilid is only a slight modification of the 
varicelliform. The resemblance to variola may, however, be so 
great that the greatest care is necessary in order to avoid error. 

Liveing * relates a good case of this kind, which had been 
refused admission at several hospitals on the supposition of its 
being smallpox. 

The absence of the characteristic premonitory symptoms of 
smallpox, the comparatively trifling rise of temperature in the 
syphilid, its slow development and course, and perhaps other 
evidence of syphilis, are the chief points to attend to. 

Anatomy. — The anatomy of the vesicular syphilids has been investi- 
gated by Cornil and others. As far as the base is concerned, the changes 
are of the same character as in the papular forms. The fluid is chiefly 
effused above the rete in the granular and corneous layers, and is con- 
tained partly in the cells themselves, partly in the cavities of the ruptured 
cells; the rete cells are also excavated, but to a less degree, unless the 
vesicle is large or becomes a pustule; then the whole rete, and even the 
papillary part of the corium, are also involved and filled with pus cells. 

There are two forms of bullous syphilid: " rupia " and " pem- 
phigoid." They differ from the other vesicular and pustular 
syphilids in not being placed on a raised red base, and the areola 
is often pink and not the usual raw-ham color. 

Rupia (Plate L, Fig. 9) is one of the most characteristic 
syphilids; as the term is not now used for non-specific lesions it 
* Fifth edition, p. 346. 



SYPHILIS. 865 

requires no prefix. Its most common period is in the second 
and third year of the disease or later, but it may also be a quite 
early eruption, as in a case I observed, in which it followed 
closely on a phagedenic chancre. It is always associated with 
profound cachexia, often, if in the secondary period, with a 
severe primary lesion, especially the phagedenic chancre, and it 
is much less common than it used to be, since improved diag- 
nosis and treatment have made the severe forms of syphilis 
comparatively rare. Its outbreak, especially if in the secondary 
period, is usually preceded or accompanied by a rise of tem- 
perature, and periostitis is common. 

It begins with the formation of a bulla, a quarter to one inch 
in diameter, the contents of which are clear or blood-stained, 
but soon become purulent; then an areola forms, the covering 
of the bulla gives way and allows the contents to escape slowly, 
and this dries into a crust, under which ulceration takes place 
and extends peripherally. The pus drying, the crust gets 
thicker, and as the ulcer extends, broader also at the base; and 
thus the characteristic stratified, conical, limpet-shell crust is 
formed, with a pink areola round it. When the crust is re- 
moved a sharply punched-out ulcer, shelving towards the center, 
is revealed, or the ulcer may be visible beyond the crust, and 
the latter may fall off before it has time to acquire the limpet 
structure. These lesions are, as a rule, few in number, but are 
sometimes numerous, situated in any part of the body surface, 
but are usually most abundant on the limbs, and may be either 
scattered or grouped, sometimes in rings. The ulcers continue 
to spread, sometimes serpiginously, unless the patient is under 
judicious treatment; they heal slowly, leaving white scars, some- 
times with a ring of pigment round them. The eruption may last 
for months by the formation of new crops of bullae, is apt to 
recur after apparent cure, and is only seen in the acquired 
disease. 

No difficulty can arise in diagnosis, unless the lesions are few 
and occur in the late tertiary period, when they may be mis- 
taken for scrofulous ulceration; but this is not common in 
adults, and evidence of past lesions, either syphilitic or scrofu- 
lous, as the case may be, is rarely wanting. The scars of 
syphilis are round, more superficial, non-adherent, thin, and 
pliable; those of scrofula, are generally irregular, adherent, and 
55 



866 DISEASES OF THE SKIN, 

seamed. The position of the lesions is often quite different, 
and may assist, with the other signs, in making the distinction. 

The Pemphigoid Syphilid,* or so-called syphilitic pemphigus, 
unlike rupia, is a rare eruption in acquired, occurring almost 
exclusively in congenital syphilis, and its existence is scarcely 
admitted by some authors. I have met with one case in a mar- 
ried woman, set. nineteen, but unfortunately no particulars have 
been preserved. It is generally almost limited to the palms and 
soles, but it may be widely spread; the contents seldom remain 
clear long. Its position, association with syphilitic symptoms, 
and amenability to mercury, are its distinctive characters. It 
is one of the manifestations of a severe form of syphilis. 

Pustular syphilids are not uncommon at all stages of the 
disease, but occurring in the early stage are, if at all extensive, 
indicative of grave cachexia. 

The small pustular or acneiform syphilid is one of the early 
and rarer forms ; its favorite positions are the face and shoulders, 
but it may come anywhere except the palms and soles, as in the 
following well-marked case, in which the eruption was general. 
Annie S., set. twenty, admitted into U. C. H. September, 1886. 
The appearance of the rash was exactly like the case repre- 
sented in Bateman's " Delineations of Cutaneous Diseases," 
1828, Plate XLIV., Fig. 1, under the name of ecthyma 
cachecticum. The pustules were flat, about one-eighth of an 
inch in diameter, on a raw-ham-red, raised base, which was 
broader than the pustule, and this again was surrounded by a 
narrow areola; these soon dried into a scab in the center, form- 
ing a three-ringed lesion, with central dark scab. The whole 
of the contents of the pustule soon dried into a crust, which fell 
off and left the raised, deep-red-tinted base, and this was suc- 
ceeded by a dirty-brown stain. These pustules were partly scat- 
tered, partly in irregular groups. Most of the eruption came 
out rather quickly, and then spread more slowly, affecting the 
whole body surface — the face last — except the palms and soles, 

* Hutchinson's Smaller Atlas, Plate XCVII., severe case; Zeissl's case 
was a typical instance; also Hardy's, Lancet, Paris correspondence, 1870, 
p. 65, man, set. thirty-eight; Tilbury Fox's, Lancet, 1874, vol. ii. p. 43, 
man, set. twenty-five; Gajasy, Berl. klin. Woch., No. 24, 1880; abs. Ann. 
de Derm, et de Syph., vol. for 1881, p. 771 — the eruption was general 
and recurrent. 



SYPHILIS. 867 

which were free, with the exception of two or three red, slightly 
raised spots on the left sole. The patient improved rapidly 
under mercury and was almost well in a month. Some of the 
papules of the larger lichenoid syphilid are frequently capped 
with a small pustule, and probably the above eruption is only 
a further development of this condition. 

Diagnosis. — Its resemblance to true acne vulgaris is not very 
great. The positions, the drying up of the pus into a scab, the 
characteristic red base, the absence of comedones, the duration 
of the eruption, the evident ill-health, and the other symptoms 
of syphilis, suffice to distinguish it. Horand * describes a ter- 
tiary eruption limited to the nose, which closely resembles acne. 
It is rare, occurring three times in a thousand cases of syphilis. 

Small pustules, single or aggregated, are not infrequent in the 
scalp, while erythematous or other syphilids are present on the 
body. They are soon covered by yellowish-gray or brown 
crusts, forming patches round a single hair group, and are called 
by some " impetiginous syphilids " or '* syphilitic impetigo. " 
They are sometimes seen on the forehead and face, and, like the 
others, are formed on a papule, though this is not apparent in 
a patch, and ulceration occurs beneath the scab and leaves a pig- 
mented cicatrix. 

The large pustular syphilids are seen only" in the cachectic. 
The so-called " ecthymatous syphilid " may be superficial or 
deep, the superficial occurring mainly in the early stage, the 
deep in the third period. The lesion commences round a hair 
follicle, forming a pustule about a third or quarter of an inch 
in diameter, drying into a greenish scab, on a raised red base, 
surrounded by the usual coppery areola, develops slowly, lasts 
for a few weeks, but fresh crops often keep up the process for 
months. It is most common on the lower limbs, but is not con- 
fined to them. Their slow development, coppery areola and 
base, the cachexia that accompanies, and the pigment scars that 
follow, are the diagnostic features. Like rupia, when it appears 
early, it is often preceded by a severe form of primary lesion, f 

Frambesioid Syphilid. — This is a rare form of ulcerating 
lesion and may occur quite early, as in the following case. A 

* Horand, " Syphilide acneique de nez," Ann. de Derm, et de Syph., vol. 
vi. (1885), p. 385- 

f There is a good portrait of the eruption in Duhring's Atlas, Plate D, 



868 DISEASES OF THE SKIN. 

man, set. thirty-two, had a sore three months previously, fol- 
lowed by no other rash but the following, which was confined 
to the face. On the chin were two shilling-sized lesions, par- 
tially coalescing, projecting abruptly about a quarter of an inch 
above the surface with a rolled edge. The surface was granular 
and fungating, and partially covered with a dried purulent crust. 
There were similar lesions on other parts of the face, but no 
other syphilids in any other part of the body. 

Nodular or Tubercular Syphilids are convex projections of 
the skin, too large to be called papules. They are most common 
in the tertiary period, but may also be an early manifestation 
accompanying or following closely upon the erythema. When 
occurring in the first year they are from a quarter to half an 
inch in diameter, sharply defined, considerably raised, of the 
characteristic coppery color, sometimes slightly scaly, occasion- 
ally breaking down and ulcerating, with thick scabs and much 
inflammation round, accompanied with much pain, and followed 
by white, depressed scars. They are solitary or few on the face, 
limbs, and trunk, but are not grouped, and some other eruption 
is often present. In the late secondary and tertiary form, al- 
though perhaps solitary at the commencement, others soon form 
round it. They are usually closely aggregated in one or two 
situations, very often on the forehead and other parts of the 
face, but in some cases cover a considerable part of the face 
bilaterally (Plate L, Fig. 10) often more closely aggregated on 
the nose and neighboring parts, the lesions varying in size from 
a hemp seed to a large pea or bean. The diffuse is less likely 
to ulcerate than the circumscribed variety; the latter may 
coalesce into an infiltration, though the component nodules are 
generally discernible, at least on the edge, and is then very 
liable to break down and ulcerate, especially when near the 
mouth, or on the nose, either where it joins the cheek or on the 
ala. On the limbs and trunk large tracts are sometimes in- 
volved, but never symmetrically. By peripheral evolution of the 
new nodules, and central involution, with or without ulceration, 
of the older ones, a cicatrix, more or less pigmented, results, 
either from atrophy or ulcerative destruction. These scars, 
with their nodular border, are very characteristic. 

These infiltrations, which are generally gummata, are 



SYPHILIS. 869 

called by some writers :< syphilitic lupus." They ulcerate ser- 
piginously, and when they occur about the face, especially the 
nose, may closely simulate lupus vulgaris; indeed, Leloir claims 
to have proved that scrofulo-tuberculosis and syphilis may be 
combined in the same lesion, but this has not yet been accepted. 
The ulcer of gummatous syphilis is covered with a thick greenish- 
brown crust, has a sharply punched-out margin and a circinate 
or reniform outline, which is very suggestive of its nature and 
may produce considerable disfigurement if on the nose, though 
it is seldom deep in other parts. The scar is usually flexible, 
white, and shining. 

Diagnosis. — From lupus vulgaris the later nodular syphilid 
may be distinguished by the following considerations: The age 
of the patient — lupus vulgaris nearly always commences in child- 
hood, a period in which this form of syphilis would be rare; by 
the nodules — those of syphilis are solitary at first, followed by 
smaller ones round each, and distinctly raised and copper- 
colored — those of lupus are multiple from the first, embedded 
in the skin, brownish, translucent, and "apple-jelly-like"; by, 
the duration — the syphilid would rarely be more than a year 
or two in duration, and syphilis would do more damage in a 
few months than lupus in as many years; besides, in most cases, 
these would be some evidence of past syphilis. Nevertheless, 
occasionally when all such evidence is wanting, as may be the 
case in women, although there will be generally a presumption 
in favor of syphilis, the evidence may be short of being con- 
clusive; then a week or two's treatment with iodids will produce 
such decided improvement in the syphilid as to remove all doubt. 

The Justus blood test is not reliable as an absolute test, as it 
may occur in other conditions, but it is a good confirmatory test. 

Subcutaneous Nodules or Gummata are, like the superficial 
lesions, common in the tertiary period, but are occasionally sec- 
ondary. A firm, painless, well-defined, pea-sized nodule can be 
felt deeply embedded in the skin. This enlarges both laterally 
and vertically, and as it approaches the surface, the skin which 
had been normal becomes of a purplish-red and adherent to the 
tumor, which softens in the center, ruptures, and discharges a 
puriform fluid, and leaves the cavity to either extend or fill up, 
according to the patient's health or to the treatment; but, under 



Syo DISEASES OF THE SKIN. 

favorable conditions, such a tumor may be absorbed before 
reaching the skin and disappear without leaving a trace. These 
gummata occur chiefly about the limbs, especially round the 
patella, and to a less extent round the elbow. So much is this 
the case that scars round the patella, not due to injuries, are 
practically diagnostic of syphilis". Before they reach the sur- 
face they may be distinguished from fatty tumors by their more 
rapid development, firmer consistence, and absence of lobula- 
tion. When they have suppurated, they differ from malignant 
tumors in their abscess-like cavity, the absence of fungation, 
bleeding, secondary enlargement of neighboring glands, and the 
smaller area of ulceration. Their structure is exactly like gum- 
mata in the liver or elsewhere. 

Lesions of the Mucous Membranes. Syphilis affects the 
mucous membranes in much the same way as the skin, but the 
appearances are necessarily modified by the different physical 
conditions of the parts; consequently such lesions are called 
mucous tubercles, mucous patches, condylomata, etc. These 
lesions are not absolutely confined to the mucous membranes, 
as they also occur in those parts of the skin where the same 
conditions of warmth and moisture obtain, such as the axillae, 
under the breasts, at the navel, between the toes, behind the 
ear, or under the chin in fat persons; but the more usual posi- 
tions are, inside the lips near the angle of the mouth, the buccal 
mucous membranes, the fauces, the tongue, and at all parts 
where the mucous membranes join the skin, such as the vulva, 
the anus and perineum, the scrotum, the angle of the mouth, 
and the nostrils. The lesions are primarily of any size up to 
half an inch or so, roundish, but, when close together, may 
coalesce into large patches. The patches are slightly raised, 
flat, with sloping margins, and, like the skin lesions, are bright 
red at first, and then brownish-red, but do not leave pigmenta- 
tion behind them. The epidermis over these elevations soon 
peels off; a thick pus is exuded, which is often offensive and 
highly contagious, reproducing similar lesions wherever it 
touches. This is often seen on the buttocks and vulva, where 
they reach their highest development, and appear to be broken 
up into segments, constituting condylomata. The infiltration 
prevents the free mobility of parts like the mouth and anus, and 



SYPHILIS. 871 

painful fissures or rhagades are formed, which leave the char- 
acteristic radiating, white scar lines, so often seen round the 
angles of the mouth. They can scarcely be mistaken for any- 
thing else; true warts in the same situations have more epidermic 
covering and are pedunculated. Moreover, mucous tubercles 
would be sure to be accompanied by other signs of syphilis, since 
they generally occur in the first six months, though solitary 
lesions may occasionally be seen in the tertiary period. 

The fauces, pharynx, and soft palate may also be affected 
with an analogous condition. Diffuse redness and slight or 
marked swelling, in the case of the uvula, are visible, and there 
is some discomfort in swallowing and slight dryness of the 
throat, or occasionally severe pain. As a rule, all this disap- 
pears in a few days, under treatment. 

Besides the erythema and mucous tubercles, shallow ulcers 
and excoriations are common on the buccal mucous membranes. 
The edges are sharply cut, but uneven, with some redness 
round them, and the surface is grayish-white from exudation, 
though the actual edge is white from sodden epithelium. They 
are seen on the pillars of the fauces, on the tonsils, the buccal 
mucous membrane, and outside the lips. On the tonsil deep 
ulcers and even sloughing may occur occasionally. 

Tertiary lesions affect chiefly the gums, hard and soft palate, 
and tongue. On the gums serpiginous ulceration, beginning 
behind the incisors and slowly extending, may be seen four or 
five years after infection and occasionally earlier. Similar erod- 
ing ulceration may affect the hard palate, exposing and leading 
to the necrosis of the bone. The appearances presented by the 
tongue lesions are very variable, from mere white patches (scars) 
to deep infiltrating and ulcerating lesions. Lewin says there 
are twenty varieties. 

Syphilitic Ulceration. Although ulceration is the outcome 
of one or other of the previously described lesions, a separate 
description may be of practical utility. Following Kaposi, they 
are of four kinds: (1) from a nodule in the skin — superficial, 
round, reniform, or serpiginous; (2) rupial — round, reniform, or 
serpiginous, with thick crusts: (3) from a cutaneous gumma — 
irregular, deep, and crater-like; (4) from subcutaneous gumma — 
irregular and deep. 



872 DISEASES OF THE SKIN. 

The typical ulcer is formed from a single nodule; it is painful 
and tender, circular, well-defined, finely indented at the edge,, 
and undermined. The margin and floor are covered with a 
grayish-yellow layer from disintegration and infiltration, which 
is circular at first, but after a time this is limited to one portion, 
amounting to about two-thirds of the circle, and the character- 
istic reniform shape is produced. The concave part cicatrizes,, 
while fresh infiltration extends beyond the convex border of the 
ulcer; the confluence of several ulcers produces serpiginous out- 
lines both in those from nodules and from rupia. The ulcers 
arising from gummata are relatively deeper and of smaller size,, 
with irregular, crater-like walls, spreading only at the orifice 
of the cavity. All syphilitic ulcers become covered with thick,, 
greenish-yellow crusts, which always require removal for diag- 
nosis and treatment. 

Phagedena * is a severe complication, which may attack the 
primary, secondary, and tertiary lesions. 

The Phagedenic chancre is often, as Bumstead and Taylor 
pointed out, the precursor of rupial, or phagedenic secondary 
lesions; but the latter may follow a sore of very simple char- 
acters, and while sometimes all the lesions become phagedenic r 
on the other hand, it may only affect some of the lesions. 

It may be serpiginous or sloughing; in the first, while spread- 
ing at one point, healthy granulations may form at the original 
position. The sloughing form resembles hospital gangrene, and 
spreads rapidly and deeply, and is attended with severe pain 
and fever. 

Although the soil is the chief etiological factor, and often 
there is cachexia from delay in specific treatment, alcoholism, 
and other excesses, or bad hygiene, pregnancy, senility, or other 
cause of diminished resistance, there is doubtless a special 
organism introduced into the tissues in addition to the syphilitic 
virus. 

Pigmentary Change in Syphilis may result from (1) in- 
crease, (2) decrease, of the normal pigment. 
(1) Increased pigmentation may arise: 
(a) From the previous eruption; 

* A good abs. of Fournier on Tertiary Phagedena in Amer, Jour, 
Cut. and Gen.-Ur. Dis., vol. xix. (1901), p. 158. 



SYPHILIS. 873 

(b) Independently of any eruption, that is to say the so- 
called pigmentary syphilid. 
(2) Loss of pigment occurs on the site of previous syphilitic 
lesions: 

(a) In the form of white spots on the site of previous 

macular or papular syphilids (leukodermia syphili- 
tica) ; 

(b) From destruction of tissue, as in the scars of ulcera- 

tive and some pustular syphilids, but there is often 
marked and persistent pigmentation of or round 
such scars, at all events at first. 

Virchow's theory of pigmentation is the one generally ac- 
cepted, viz., that it is due to blood-coloring matter, which 
permeates the tissues, and is deposited partly outside the cells 
as hematoidin crystals, and partly within the cells as pigment 
granules. Neumann * says that the pigment in syphilis is 
found both in the exudation and connective-tissue cells, and free 
in the necrotic tissue of the rete, and also in thin, threadlike 
tubes (processes of cells) which carry the pigment. When the 
pigment is only in the exudation cells and rete, it may disap- 
pear sooner or later, by absorption or desquamation, as occurs 
after macular, papular, and some pustular syphilids. 

When it is inclosed in the connective-tissue cells, which may, 
in some cases, be completely filled except the nucleus, the pig- 
mentation persists for a very long time and may be permanent. 
This is seen on the borders of scars following syphilitic ulcera- 
tion and many pustular lesions, after cutaneous gummata, and 
some grouped papules; the pigment is here granular. Neu- 
mann is convinced that the white spots following papules and 
maculae are produced by the epidermis being cast off, and the 
newly formed epidermis not taking up any pigment. Pig- 
mented cells, however, remain from eight to eighteen months 
in the papillary layer, partly between the connective-tissue cells, 
partly round the blood and lymph vessels. Riehl confirms this. 

Frattali, from histological examination of the pigmentary 
syphilid, concludes that the pigmentary syphilid is consecutive 
to a pericapillary infiltration of the most superficial layers of 
the derma. 

Hjelmann, in addition, finds a considerable increase of pig- 
* Loc. ct't., p. 223, et seq., in which the whole subject is discussed. 



874 DISEASES OF THE SKIN. 

ment in the derma. The leukodermia he ascribes to the oblitera- 
tion and atrophy of the vessels. 

Ehrmann says that the production or absence of pigment de- 
pends on the presence or absence of melanoblasts. 

Pigmentary Syphilid * (Plate II., Fig. n). Synonym. — Syph- 
ilitic leukodermia. This was first described by Hardy in 1853. 
The most common period for its development is from the sixth 
to the twelfth month of disease, but it may also come quite 
early, or in the second or third year. In a case of mine, a young 
married woman, it appeared about the third month, and was 
limited to the neck, and accompanied by the erythematous 
syphilid, which she averred had not preceded the pigmentation; 
and in a case of acquired disease, in a girl of nine years, it 
occurred in the sixth month. It is rather a rare condition, but 
is seen much more frequently in women than in men, in brunettes 
more than in fair women, and seldom after the age of thirty- 
five, but Chambard records a case in a man, set. seventy-one. 
Gemy records a case in a boy from hereditary syphilis. Its seat 
is chiefly on the neck, especially at the sides and back; and it 
may occasionally be seen on the face, chiefly on the forehead, 
the chest, or flanks, but rarely on the limbs. The lesions are 
irregularly margined, round or oval spots, from an eighth to 
one inch in diameter, well or ill-defined, with a yellowish-brown 
color, but the surface is otherwise unaltered; they may be obvi- 
ous, or require looking for, discrete or confluent, and the skin 
in the intervals between them appears abnormally white, though 
whether it really is so is a disputed point. It may be the only 
symptom of syphilis, but is more frequently only one of many. 
Most German authors * regard it as simply a leukodermia of 
syphilitic origin on the site of a previous roseola; but Taylor of 
New York, while admitting that there is a syphilitic leukodermia, 

* Literature. — Hardy, "Maladies de la peau" (Paris, 1858), p. 154. 
Taylor, Amer. Jour. Cut. and Ven. Dis., vol. iii. p. 97, — a good article 
with chromo-lithograph; and at p. 218 same volume is an abstract of 
Maireau's " These de Paris." Fournier, " Lecons sur la Syphilis," also 
gives chromo-lithograph. Santin also has written an inaugural thesis 
upon it. 

\ Poelchen, "Vitiligo acquisita Syphilitica," Virchow's Archiv, Bd. 
cvii., p. 535, with plates, says nearly all women's necks are pigmented, 
and that the roseola spots remove a part of this when they fade. 



SYPHILIS. 875 

having watched the development of a large patch from the time 
when it was not larger than a pin's head, considers the pig- 
mentary syphilid to be sui generis, and that the leukodermia is 
only simulated. According to Neisser and Riehl, it is really 
a displacement of pigment, which is less at one part and in- 
creased all round. It lasts from two months to several years, 
is uninfluenced by treatment, and is sometimes permanent. Ehr- 
mann says that it is produced only in those parts of the skin 
where there has been a preceding syphilid, which has involved 
the corium and destroyed the pigment-carrying cells, or 
changed them into unpigmented ones. Darkening of the skin 
ensues if the deeper layers are involved. If this is true the 
lesions are certainly not visible on the surface either before the 
loss or increase of the pigmentation. 

Diagnosis. — It should not be mistaken for the pigmentation 
following the erythematous or other syphilids, while from tinea 
versicolor the distinction is easy; from its position, and the fact 
that the color is in, not on the skin, and that there is no fungus. 
From uterine chloasma the conditions under which it occurred 
would be the best guide. 

Purpura may be seen occasionally on the lower extremities, 
and its relations to acquired syphilis have been discussed by 
Stephen Mackenzie f and others. Derville records a case where 
dark red spots from the size of a pea to a haricot bean ap- 
peared on the legs in the first fortnight of the disease; al- 
buminuria was present, and intolerable itching preceded and 
accompanied it. In a case of Neumann's, a man, set. fifty-one, 
there were discoid plaques on the forearm with ulceration in the 
center, similar crusted plaques on the sternum, and hemorrhagic 
follicular papules on the lower limbs. There were also hemor- 
rhages in the mucous membranes. In congenital syphilis it is 
more common and important, as Behrend has shown. The pos- 
sibility of its being produced by iodid of potassium must be 
borne in mind. 

Late Palmar Squamous Syphilid (Plate II., Fig. 12). This 

is a dry scaly lesion, occurring as a reminder, perhaps, many 

years after infection. It is seen chiefly on those who do manual 

labor or in other ways have much grasping or friction of the 

\Med. Times and Gazette, vol. i. (1879), PP- I 73- 2 79> 5 QI - 



876 DISEASES OF THE SKIN. 

palm. It may occur either in the form of denudation of the 
horny layers in small areas bounded by a scaly collar, as in the 
plate, or as thickening and Assuring very like a dry palmar 
eczema, from which it differs in having a rounded serpiginous 
border. It also commences usually in the center of the palm, 
while eczema often begins outside the palm and affects that 
secondarily. 

Alopecia. Loss of hair may occur in four ways. In the sec- 
ondary period there may be a general thinning of the hair, as 
a part of the general malnutrition, occurring at the third month 
and onwards. This may be of various grades, from being hardly 
noticeable up to very extensive but irregularly distributed bald- 
ness, as in R. W. Taylor's case,* which he ascribes to the com- 
mingled seborrheic process. The hair may also come off in 
round patches, like alopecia areata; e. g., Ethel F.,f set. twenty- 
six, had symmetrical patches, an inch and a half in diameter in 
various parts of the scalp, a squamous eruption, and ulcerated 
sore throat and tongue. The hair was rapidly restored by 
specific treatment. In cases of more severity the alopecia may 
spread to one or more additional regions, such as the eyebrows 
(especially in women, which, according to Fournier, is character- 
istic), the beard, the axillae, or the pubes. In an exaggerated 
but rare variety of this form there may be complete general 
alopecia, the patient being left without a single hair in any part 
of the body. These cases readily respond to mercurial treat- 
ment, as a rule, and in all the preceding forms the hair grows 
again within five or six months. The symmetry of the patches, 
the amenability to treatment, and the presence of other symp- 
toms of syphilis, would distinguish the patchy form from 
alopecia areata. An incomplete, patchy loss of hair may also 
occur on the site of eruptions, from the inflammation involving 
the hair follicle; this is transitory. In the tertiary period the 
hair may also be lost, but in a less direct way; bald patches may 
be left by ulcerative or pustular lesions destroying the whole 
skin structure and producing scars; this is of course irremedia- 
ble. General thinning, leading to extensive and often permanent 

* " The Seborrheic Process and the Early Syphilitic Eruptions," Jour. 
Cut. and Gen.-Ur. Di's., vol. viii. (1890), p. 165. 
fU. C. H., O. P., No. 69, 1880. 



SYPHILIS. 877 

baldness, may be consequent upon seborrhea, which is a not 
infrequent sequence of syphilis. The local treatment for sebor- 
rhea, combined with the general treatment for syphilis, offers 
the best chance of restoration. In old syphilitics the hair is also 
often left harsh, dry, and wiry. 

Nail Affections.* These are of two classes: one, those due 
to lesions of the bed or matrix, or both, constituting onychia 
(chronic); the other due to lesions round the nail, perionychia 
(acute or chronic). In the first class the changes are nutritive. 
The nail may be brittle, chipped at the free border, discolored, 
pitted, and furrowed, or it may be gradually and painlessly 
separated from its attachment, either wholly or partially, be- 
ginning either at the free or attached border. Sometimes, while 
separation is going on at one end, re-attachment takes place at 
the other, and so the fall is avoided, but it is always left fur- 
rowed and irregular. Thickening of the nail may also occur, but 
it is less common than the deficiency in nutrition. The thick- 
ening occurs chiefly at the free border, where it is rough and 
chipped, or ridges may form, but the proximal part of the nail 
is often unchanged. 

Perionychia may begin in three ways. 1. By the extension 
of a squamous lesion to the matrix; the nail over the affected 
area scales off, and forms white pits, while the outlying border 
of the skin may get thickened, brittle, and bleed easily from 
fissures. 

2. Inflammation occurs; the skin round becomes swollen and 
dusky red, but does not go on to suppuration, unless the swell- 
ing pressing on the edge of the nail causes ulceration, then the 
tissue fungates over the nail and gives exit to a fetid discharge, 
and the nail itself becomes necrosed and black or otherwise 
discolored. Unless exposed to pressure, as in the toe-nail, it is 
not usually painful. 

3. Gummatous infiltration of the matrix has also been 
recorded. 

Children. — Acquired syphilis in children or infants presents 
much the same symptoms, and runs much the same course as 

* For a more complete account of syphilitic nail affections see Fournier's 
" Syphilis chez la femme " (1873), p. 467. 



878 DISEASES OF THE SKIN. 

in the adult, except that in very young children the bones, at 
the junction of the epiphyses to the shaft, are very likely to be 
the seat of inflammation. Thus, one of my cases, a child, set. 
six months, infected by being suckled by a syphilitic woman, not 
its mother, when three months old had ophthalmia, dactylitis 
syphilitica of both hands, left facial paralysis, and subcutaneous 
gummata, some of which suppurated. In another, where the 
child was well up to nine months old, and then contracted 
syphilis from its mother, who had been infected by her sailor 
husband six weeks after her confinement, there was epiphysitis 
of the lower end of the left humerus, of the right olecranon, 
and of the heads of both tibiae, when the child was a year and 
a half old; it had had a rash all over the body and a sore throat 
nine months before. 

Congenital Syphilis — i. c, the syphilis transmitted by the par- 
ents to the fetus in utero — presents some peculiarities both in 
the eruptions and other symptoms, but, at the same time, pos- 
sesses many resemblances or analogies to the acquired form. 
Unlike phthisis, gout, etc., it is not a mere predisposition that 
is inherited, so that the manifestations may be in abeyance until 
the surroundings or habits of the patient call them out, but the 
disease itself is transmitted. 

Its effects may be shown, by the death and premature expul- 
sion of the fetus; by live birth with the disease in full activity, 
in which case the child seldom survives long; or, what is more 
common, it may be born comparatively healthy and several 
weeks elapse before the disease declares itself. Which of these 
several effects shall be produced — and there are various grades 
in each class — depends chiefly upon the length of time that has 
elapsed between the infection of the parents and the birth of 
the child, and also upon whether they have undergone effectual 
treatment. Whether the disease can be transmitted by the father 
alone, the mother remaining unaffected, need not be discussed 
here, more than to say that in seeking for corroborative evi- 
dence from the parents it is necessary to be aware that the 
mother of an undoubtedly syphilitic infant may display no evi- 
dence of the disease herself, either in her history or at the time, 
though such women, quite late in life, may have some tertiary 
lesion. With regard to the father, he can transmit the disease 



SYPHILIS. 879 

to his offspring long after it has ceased to be contagious to 
others, and though he believes himself to be perfectly well. 

The symptoms of congenital syphilis are of two classes: the 
early, which occur in the first two years of life, and the late, 
which either commence or persist after that period. 

The earliest symptoms nearly always show themselves in the 
first three months of life, and are never later than six months,* 
while in the majority of cases it is within from three to eight 
weeks. Thus, in 249 cases collected by Roger, f in seven-eighths 
the disease appeared before the end of the third month, and 
in nearly half in the first month; in Kassowitz's 124 cases none 
occurred later than three months. 

The symptoms that may precede, accompany, or follow the 
eruptions are very numerous, since any tissue or organ of the 
body may be affected; but the most common in the early stage 
are those due to inflammations of the mucous membranes of the 
nose, mouth, and larynx, the pericranium and epiphyseal junc- 
tion of the long bones, the spleen, liver, and iris. The first 
symptoms are pallor, peevishness, and pyrexia, soon followed 
by the well-known and almost characteristic " snuffles," due to 
inflammatory swelling of the lining membrane of the nose. 
This obstructs nasal respiration, which may be stopped alto- 
gether by the accumulated secretion, and so prevent sucking, 
and will, if the child is not fed at once with a spoon, materially 
hasten the end. One or more of the eruptions and excoriations, 
to be presently described, soon follow or occasionally precede 
the coryza, most of them commencing and becoming worst 
upon the buttocks; mucous tubercles are seen about the mouth 
and anus, and rhagades round all the apertures; the child wastes; 
the skin gets loose and wrinkled; the complexion is of a sallow 
or cafe an lait tint; the face acquires a curious " old man " ex- 
pression, as if the cares of this life were already too much for 
him; the skin is stained by the faded eruptions and disfigured 
by more recent ones; the hair is scanty, especially at the tem- 
ples, which, with the eyebrows, are often bare; and if the larynx 
is affected the cry is hoarse or even toneless. The spleen is 
often enlarged, — in a quarter of the cases, Gee says, — and if the 
enlargement is great, it is often associated with profound 

* Trousseau puts it at seven months, and Cullerier at a year, 
t Quoted by Lancereaux, vol. ii. p. 137, " New Syd. Soc." 



880 DISEASES OF THE SKIN. 

anemia and bone-changes; this combination is more common in 
the second year, when perhaps all the skin lesions have disap- 
peared; the liver is less frequently and conspicuously enlarged. 
The changes in the skull are due to thickening of the bone on 
the one hand, or thinning on the other. The thickenings may 
be circumscribed or diffuse, the latter being an advanced stage 
of the former. The circumscribed thickenings or bossy enlarge- 
ments are easily felt and often visible. They are really nodes, 
which are formed chiefly upon the frontal and parietal bones 
surrounding the anterior fontanel, but not reaching up to its 
edge (natiform thickening of Parrot). The parietal and frontal 
eminences are the last parts attacked, and, except in advanced 
cases, are left as islands of healthy, smooth bone surrounded 
by the vascular, roughened, diseased bone, which seldom reaches 
quite up to the sutures. These bossy enlargements are easily 
palpable and often visible. In the diffuse form, which affects the 
frontal bone chiefly, there may be osteitis as well as periostitis. 
Cranio-tabes, of which there are all grades, up to the total wast- 
ing of the bone substance in some spots, can be felt in the 
posterior part of the parietal bones, and behind the mastoid 
process. It is not confined to congenital syphilis, but is very 
common in that disease. The other form of thinning occurs on 
the inner surface of the skull, and is only of post-mortem inter- 
est. The thinnings and thickenings may be not infrequently 
seen on the same skull. Nodes may also be seen on the long- 
bones occasionally in infancy, but are more frequent at a later 
age. The chief affection of the long bone is inflammation at 
the junction of the epiphysis and diaphysis, which is attended 
with heat, swelling, tenderness, and pain on movement, so as 
to produce a pseudo-paralysis. It may be seen at a very early 
age (one of my cases was only three months), affecting the 
ulna, radius, and tibia, but not symmetrically. The so-called 
" dactylitis syphilitica " is probably of the same nature as this 
epiphysitis. The cranial changes may also begin very early. 
In an infant who died at ten days old, after having had a bullous 
eruption with excoriations, the whole of the skull surface, ex- 
cept the parietal and frontal eminences, was red and roughened. 
In the last stage of congenital syphilis the skin lesions are 
seldom of importance, and generally absent; lesions of the eye, 
ear, bones, teeth, and viscera, and occasionally of the nervous 



SYPHILIS. 88 1 

system, are those chiefly met with, and since they occur inde- 
pendently of skin eruptions, need not be gone into here. Gum- 
matous infiltration of the skin with ulceration, very similar to 
that seen in the acquired disease, is to be occasionally 
observed. 

The various symptoms enumerated, of which only the most 
common have been mentioned, are, of course, not seen all to- 
gether in one patient; they occur in various combinations, and 
at various periods, but may all be present in the first year of 
life, and most of them within the first three months. 

The following skin eruptions are met with: 

An erythematous rash or roseola, resembling that of ac- 
quired syphilis, is rare in infants. In Bassereau's oft-quoted 
case, a papular syphilitic erythema appeared on the face and 
then on the body on the third day of life, soon followed by 
coryza. 

Cullerier records its appearance at birth. In a case at Shad- 
well, set. two months, the rash had been present one month; the 
whole body surface was covered with maculae half an inch in 
diameter, brownish-pink in color, with some scaliness in parts. 
According to Diday, the abdomen, lower part of the chest, and 
inner surface of the limbs are the usual positions for the bright, 
soon becoming coppery-red, irregularly outlined, finger-nail- 
sized patches, generally associated with ulcers of the mouth and 
anus. 

Another form of erythema, however, is the most common of 
all the congenital syphilids, consisting of erythematous patches 
of various sizes, which usually commence on the buttocks and 
round the anus. They may be well or ill defined at the edge, 
bright coppery or yellowish-red. tending to coalesce into large 
sheets of eruption, but generally patchy on the borders. This 
erythema may extend uniformly on the back and inner side of 
the legs, quite down to the feet, including the soles, which are 
bright red and peeling. On the front and outer side it is still 
generally patchy; upwards, it often extends to the loins and ab- 
domen, and in a few cases, all over the body, in patches which 
coalesce; the whole surface is then red and desquamating on the 
dry parts, while on the buttocks, or where it is exposed to 
moisture, the scales are soaked off and the surface is left raw 
56 



882 DISEASES OF THE SKIN. 

or brightly glistening. These generalized cases are very likely 
to die. 

Diagnosis. — This eruption is at first liable to be mistaken for 
intertrigo, but this is never in well-defined patches, does not 
extend below the parts covered by the napkin, and yields 
readily to simple measures of protection and cleanliness. In 
specific erythema, snuffles and other syphilitic symptoms are 
generally present also. It must be borne in mind, however, that 
intertrigo is very easily excited in syphilitic children. Mothers 
often ascribe both these conditions to the " thrush having gone 
through it," and will admit this, while they will deny that a child 
has ever had any eruption on its buttocks or elsewhere. 

This erythema differs from the exanthem of acquired disease, 
in the great tendency to coalesce, in being raised above the sur- 
face and often well defined, and in the greater tendency to des- 
quamation, even at an early stage. 

The next most frequent lesion is mucous tubercles. In the 
early stage they are generally associated with other lesions of 
the skin, but are sometimes alone with snuffles, and are often 
the sole relapsing lesion from the first to the third or fourth 
year. They are especially common, but not confined to the anus 
and angles of the mouth, occurring wherever there is warmth 
and moisture, such as the groins, axillae, and between the toes;, 
they resemble those seen in the adult, but are more frequent 
and numerous. Superficial excoriations about the anus and 
buttocks, generally on the site of an erythematous, squamous, 
or other lesion, are very common, as are also rhagades at the 
angles of the various apertures, such as the anus, mouth, nos- 
trils, eye, etc., due to the inelastic and brittle condition of the 
epidermis of those parts, the result of erythematous and other 
lesions. 

A papulo-squamous eruption, corresponding to that of ac- 
quired syphilis, is the next most common, consisting of round 
superficial patches, from one-eighth to half an inch in diameter, 
very slightly raised above the surface, delicately scaly, with a 
pink or reddish-brown color at first, but after a few days of 
a pale fawn tint. It may be limited to one or more regions, 
such as the limbs, forehead, or round the mouth, or occupy the 



SYPHILIS. 883 

whole body surface, usually in discrete patches; it commences 
upon the buttocks, where superficial ulceration is apt to occur, 
from the irritation of the urine and feces. A variety of this is 
a crescentic squamous eruption with a raised border, which, in 
one of my cases, began on the buttocks a week after birth, then 
spread over the thighs, and then all over the body, forming 
maplike outlines on the skin, most marked over the lower part 
of the body and legs. A definite circinate scaly eruption, resem- 
bling that seen in the acquired form, is also to be observed. 

The small papular forms are acuminate, convex, or flat. The 
first two are bright or brownish-red, of extensive or limited 
distribution, occurring chiefly on the limbs, sometimes in groups 
of three to six, sometimes scattered irregularly; they may be 
crowned with a scaly cap or with a small bead of pus, seldom 
with a clear vesicle. When the pustular element is the pre- 
dominating one, it is generally an early manifestation; in one of 
my cases it began on the third day of life, and was associated 
with small squamous patches of the buttocks and thighs, while 
the pustular element was most marked on the face. The flat 
papules are not so common as the others; they are slightly 
raised, shining, and angular, or roundish, grouped in irregular 
patches, but with not much tendency to coalesce, and are very 
like infantile lichen planus, but their outline is often rounder, 
the color is duller in hue, and other evidence of syphilis can 
generally be found; e. g., a boy, aet. two months, had snuffles 
badly, erythema on the buttocks, when three weeks old, still 
present all over the genitals, and below the knees, while on the 
shoulders and neck were flat angular papules like lichen planus; 
a few isolated flat patches, about a third of an inch square, were 
also present. 

Vesicular eruptions are rare in congenital syphilis, and are 
scarcely ever the first form of eruption. They vary much in 
character and size, e. g., a boy, aet. four months, had brown dis- 
colored desquamating patches over the legs, arms, and face, 
slightly on the trunk, ulcerating on the buttocks; a week later 
vesicles appeared singly and in groups, a millet seed in size, 
with little or no redness at their base; the following week they 
had developed into bullae from a pea to a hazelnut in size; the 



884 DISEASES OF THE SKIN. 

general condition was, however, improving, and in another fort- 
night he was well. 

Pustular eruptions are much more common than the vesicu- 
lar; besides the small pustules that sometimes crown papules, 
already described, there are ecthymatous-looking sores, with a 
greenish crust concealing the sharp-edged spreading ulcer, or a 
simple excoriation. They are never very numerous, are asso- 
ciated with other lesions of syphilis, are generally indicative of 
profound cachexia, and are often the prelude to death; some- 
times they are the first skin eruptions, but not often. Super- 
ficial suppuration is very likely to occur where the parts are 
frequently moist, such as round the genitals, and the pus from 
these and other lesions may become inoculable, and so impetigo 
contagiosa supervenes in an unmistakably syphilitic child. 

Another form is described by Barlow, of small cutaneous 
purplish-red abscesses which resemble boils, but have no core. 
F. Taylor has reported two cases, and I have had several. 

Bullous eruptions of pemphigus character are more common 
in congenital than in acquired syphilis, while rupia is hardly 
ever seen; Schiff, however, has reported a case in a child, set. 
eleven months. This so-called " syphilitic pemphigus " gen- 
erally appears in the first week; the child is often born with it, 
either dead or alive. The hands and feet, especially the palms 
and soles, are the almost invariable localities for its onset, and 
it is often confined to these situations. In addition, the nail 
bed is frequently attacked, with consequent destruction of the 
nail, which often turns black; when less severely attacked it is 
contracted * at the proximal end, as if pinched up, and spreads 
out like a fan at the free end. The lower part of the face is 
the next most common position, while the trunk generally 
escapes, except in very bad cases ; thus in Labat's case f the 
child was born with pemphigus all over, except on the palms and 
soles, which were red and shining; it died in twelve hours. The 
bullse are either flaccid or tense, contain pus or blood, with a 
dusky red areola round them, or they may be on a raised, deep- 
red base. When they rupture or dry up, greenish-yellow or 
dark-green scabs are formed, which conceal an unhealthy- 

* Hutchinson on Syphilis, Plate VIII., p. 416. 
\Progres Medical, October, 1880. 



SYPHILIS. 885 

looking, spreading ulcer. The eruption is always an indication 
of great severity in the disease, and the child seldom lives long, 
either dying of general cachexia or of diarrhea, or other inter- 
current affection. I have, however, seen one severe case where 
the eruption was present at birth recover under immediate mer- 
curial treatment. Milder cases, where the contents of the bullae 
are clear instead of purulent, have a much better chance; but 
when Hochsinger speaks of twenty recoveries out of twenty- 
three cases, this is such a large proportion, and so contrary to 
general experience, that he must, I think, have included cases of 
non-specific pemphigus neonatorum. 

There is seldom any difficulty in the diagnosis from ordinary 
pemphigus; the nature of the bullae, their position on the palms 
and soles, while the trunk is usually free, and the strongly 
developed cachexia are enough. Its occurrence in the first week 
of life distinguishes it from pemphigus vulgaris, but not from 
the form described already as occurring in the newborn in 
lying-in institutions, and in bad hygienic conditions, but in this 
last the contents of the bullae are clear, they appear anywhere, 
and the children get well rapidly, if removed from their un- 
healthy surroundings. 

Bullae may, however, occur in connection with syphilis at a 
later stage, as in the case described with vesicular eruptions; 
for another example, the following may be related: 

In a child,* sixteen days old, bullae with clear contents, from 
a quarter to one inch in diameter, were present on the trunk 
only; there were snuffles and a depressed nose, but no rash on 
the buttocks. The history was that when thirteen days old a 
dry, scaly eruption appeared round the mouth, followed by the 
bullae on the trunk; there had, however, been one on the neck 
when three days old; the mother had had eight abortions. The 
child died when a month old. 

Nodular eruptions are among the late manifestations of con- 
genital syphilis, but are not common; they present similar ap- 
pearances to the late lesion in acquired syphilis, but are seldom 
so extensive. They were so, however, in a woman, aet. twenty- 
two, admitted into U. C. H., with evidence of congenital 
syphilis in the eyes and teeth, as well as in her skin and in her 

*U. C. H., Out-patient, No. 575, 1880. 



886 DISEASES OF THE SKIN. 

past history. The patient had suffered from nodular infiltration 
and ulceration for four years, and there were numerous scars 
about her, extensive serpiginously ulcerating patches, situated 
all over the right scapula, the upper third of the right arm, and 
the upper surface of the left breast, and numerous convex, hazel- 
nut-sized nodules were scattered over the upper part of the body. 
These gummatous infiltrations are almost the only skin lesions 
in late congenital syphilis, but Smirnoff records two cases of 
leukodermia in women, set. twenty-three and thirty-three re- 
spectively, which he ascribed to their having had hereditary 
syphilis. 

The prognosis in congenital syphilis is bad in proportion to 
the number, severity, and general distribution of the lesions; it 
is bad also when they appear at or soon after birth, or if they 
affect the nutrition of the child. In cases occurring later than 
the first month, if the nutrition is good, treatment is almost 
always successful, though in a few cases, after all the skin and 
other troubles have apparently disappeared, the child, without 
apparent cause, becomes marasmic and dies. Treatment should 
always be energetically carried out to the end, as the most 
desperate-looking cases are often saved. 

Treatment. — In spite of the most assiduous study by a host of 
trained observers, almost unlimited opportunities for the trial of 
any method of treatment, the ready response in most instances 
of any lesion present to the treatment suitable for it, and finally 
the general acknowledgment that practically there are only two 
drugs that exercise a decided and unmistakable influence on the 
manifestations of the disease, it is strange how little agreement 
exists as to the details of treatment, either as regards the special 
preparations of the so-called specifics, the best time to com- 
mence them, how long they should be continued, the best mode 
of administration, when one and when the other drug should be 
given, whether they should be given together or apart, simultane- 
ously or alternately. All that- can be done in this work is to 
set forth briefly the different modes of treatment chiefly in 
vogue, and to point out their limitations and indications accord- 
ing to the author's judgment and experience. 

It is not necessary to go into the treatment of the primary 
sore in this work, beyond saying that the early excision of it has 
been unsuccessful, and it should be reserved for cases where 



SYPHILIS. 887 

the chancre is on the under surface of a long prepuce, and cannot 
be properly dressed; then circumcision would be indicated. The 
first question to be considered is, whether specific treatment 
should be commenced as soon as the indurated chancre comes 
under notice, as is recommended by the majority of French 
authorities, or to follow the German school, and wait for the 
appearance of secondary manifestations. Hutchinson is a strong 
advocate for the abortive treatment, and asserts that by the early 
and continuous use of mercury in a mild form, generally one 
grain of gray powder three times a day, for from six to twelve 
months, it is possible to suppress the secondary stage alto- 
gether, the few exceptions being chiefly those who were in- 
tolerant of the drug, and in them the symptoms take a mild 
form. Few, I think, can claim such an almost uniformly happy 
experience as this, one of the chief objections to the abortive 
treatment being that it has so little influence in preventing sec- 
ondary manifestations, and that by depressing the health of the 
patient, it renders him less liable to resist the secondary effects. 
There are several arguments against this; but without possess- 
ing the complete confidence of Hutchinson, my own practice 
would be that, if there is an undoubtedly indurated chancre, a 
mild course of mercury should be commenced at once; but, if 
there is any doubt of its being a sore which will lead to constitu- 
tional infection, that little harm will accrue by waiting for further 
^development ; while if specific treatment be adopted, and no 
symptoms follow, the patient may have been needlessly sub- 
jected to a trying treatment, and his life may be embittered, by 
his erroneously believing himself to have had a disease so often 
dire in its effects on himself and others. 

Everyone knows that mercury and iodid of potassium are the 
backbone of the treatment for syphilis. Other drugs, chiefly 
diaphoretics or diuretics, such as guaiacum, sarsaparilla, Zitt- 
mann's decoctions, of which sarsaparilla * is the main ingredi- 
ent, Tayuya, Dade's bamboo extract, erythroxylon coca, sulphur, 
and iodoform have had an ephemeral reputation, and, though 

* Calomel and sulphuret of antimony are also added, but as they are 
insoluble salts and the supernatant fluid is poured off clear, there cannot 
be much mercury in the clear docoction. The remedy, however, still has 
a wide reputation in Germany, and Alfred Cooper is a strong supporter 
of it. For its exact composition and mode of administration, see Mixtures, 
F. 27, among the formulae at the end. 



888 DISEASES OF THE SKIN. 

sometimes useful as adjuncts are quite unreliable by them- 
selves. 

Hot baths, especially those containing sulphur, are useful ad- 
juncts to the inunction cure, facilitating the diffusion of mercury 
through the system. Aix-la-Chapelle and Bareges may be espe- 
cially mentioned. 

The problem of the treatment of syphilis is not, however, so 
simple as it seems; few diseases require more judgment and 
experience, in order to secure the best results with the drugs, 
and, at the same time, to avoid or minimize the injurious effects 
which their injudicious employment will certainly produce, or 
which are due to a special sensitiveness to them on the part of 
the patient. While, therefore, the aim must be to thoroughly 
antagonize and overcome the syphilitic virus, and remove the 
various lesions it produces, as they arise, by the internal and 
external administration of these valuable remedies, the absolute 
necessity of keeping or raising the vital power of the patient 
to its highest capacity must ever be borne in mind. In the 
presence of conditions depressing both the mind and body of 
the patient, mercury and iodids are often powerless, while, if 
mercury be given so as to get its depressing effects, mild lesions 
are often converted into severe ones, a papule becoming a pus- 
tule, or a nodule breaking down into an ulcer, and fresh lesions 
appear. 

Mercury may be administered by the mouth, by the skin, and 
by intramuscular and intravenous injection. If through the 
skin, it may be given by inunction, by calomel vapor-baths, or 
by corrosive sublimate water-baths. Corrosive sublimate baths, 
in the proportion of two grains to the gallon, have been recom- 
mended for congenital syphilis, but there are better methods 
than this. 

Where there is opportunity for calomel vapor-baths they are 
extremely valuable in the early stage, especially where there 
are extensive eruptions, as the patient has both the external and 
internal beneficial application of this drug. The mode of admin- 
istration is given among the formulae (Baths, F. 4). They are 
most suitable for robust patients before they are broken down 
by the disease, and may be given daily, or every other day, 
watching their effect, and stopping them at once, if they are 
depressing the patient, as they are liable to do. Where they 



SYPHILIS. 889 

cannot be taken daily, it may be advisable, at first, to give some 
mild preparation by the mouth also. They are also very useful 
in tertiary ulceration of the limbs, the affected limb only being 
exposed to the vapor. 

Inunction of ung. hydrarg. is another most valuable method, 
especially where mercury cannot be given by the mouth; in 
congenital syphilis, it is almost universally employed, but for 
adults is not used so much here as it is on the Continent, where 
in conjunction with baths, or Zittmann's decoctions, it is the 
chief method prescribed. The Aix-la-Chapelle method is a cele- 
brated cure, founded on this plan; it also is explained in the 
Appendix. A piece of ointment, the size of a hazelnut, should 
be thoroughly rubbed in daily, where the skin is thin, such as 
inside the thighs and arms, the flanks, etc., changing the site of 
inunction frequently, to prevent local irritation or the so-called 
mercurial eczema being excited, and frequent baths are neces- 
sary, to place the skin in a favorable condition for absorption. 
The chief objection to it is that it is a very dirty plan, requires 
the patient to give himself up to treatment, which many cannot 
do, and is difficult to carry out without exciting the suspicion 
of the patient's friends as to the nature of his malady; patients 
also can seldom carry it out efficiently for themselves, and it is 
expensive, and not devoid of risk of mercurialism to the rubber. 
One great advantage is that damage to the digestive organs, 
which so often ensues from mercury given internally, is quite 
avoided. 

Hydrargolum (colloid mercury) has been recommended 
in ten per cent, ointment, as more readily absorbed and 
less irritating than unguentum hydrargyri. It is equally dirty. 
Calomel has been proposed as a cleaner substitute for the un- 
guentum hydrarg., seven or eight grains a day being rubbed in. 
The formula is calomel one part, lanolin four parts, cocoa butter 
one part. Ruata and Borera claim success with this plan. Mer- 
curiol, an amalgam with tin and aluminium, containing forty per 
cent, of mercury, has also been recommended, as it has been 
considered that mercurial inunction is really due to inhalation 
of mercury. Welander had bags made containing flannel on 
which ung. hydrarg. had been rubbed. The bag was worn con- 
stantly round the neck. Subsequently mercuriol was substi- 
tuted, and Blaschko strongly advises a cleanlier method, using 



890 DISEASES OF THE SKIN. 

mercolint * suspended round the neck. Five grains are placed 
in a flannel bag and fastened on the skin. 

Injections deep into the muscles were strongly recommended 
by Lewin first, and latterly by many Continental authorities, and 
by Astley Bloxam f in this country. The buttock, where the 
gluteus is thickest, is the part generally selected, the trapezius, 
two inches above the superior angle of the scapula, being the 
next best place. The needle, which should be carefully sterilized 
in alcohol, should be plunged deeply into the muscle, and the 
injections should seldom be given oftener than once a week. 
They should not be given subcutaneously, as they are more 
painful, and very likely to produce sloughing. 

Various preparations have their advocates. They may be 
divided into soluble preparations, such as the perchlorid, 
peptonate, bicyanid, sozoiodolate, the benzoate, the alanin, suc- 
cinimid, the double hyposulphite of mercury and potassium. 
Of the above the perchlorid and sozoiodolate of mercury are 
most commonly employed. The latter is gradually superseding 
the perchlorid, as it is so much less painful: it is claimed that the 
double hyposulphite is even less painful. A quarter of a grain 
of perchlorid in twenty minims of distilled water, with or with- 
out a quarter of a grain of common salt, is given once or twice 
a week. Bloxam says once is sufficient. The formula for the 
sozoiodolate, which is the salt I use, is sozoiodolate of mercury 
and iodid of sodium, of each three grains, distilled water 5iv; 
inject twenty minims into the buttock once a week. The iodid 
of sodium is required to make the mercury salt soluble. The 
double hyposulphite is dissolved in distilled water the twenty- 
fifth of a gram to ten grams; a cubic centimeter of the solution 
is equal to one-sixth of a grain of corrosive sublimate. 

The insoluble salts are calomel, the yellow oxid, or Lang's 
gray oil; and the salicylate, \ the oxyphenate, etc. Those 
chiefly employed are calomel, the yellow oxid, and Lang's gray 
oil. Jullien recommends one and a half grains of calomel with 
a cubic centimeter (about fifteen minims) of petrolene every 

* Ordinary cotton, homogeneously permeated with mercury, by Beiers- 
-dorf. 

f Laticet, August 21, 1886. 

X Symptoms of acute poisoning following a single injection of four centi- 
grams is recorded by Glagoleff in Russia. Abs. in Amiales de Derm. 
~et de Syph., vol. vi. (1895), p. 177. 



SYPHILIS. 891 

second week for several months, and then every twenty-five or 
thirty days. The yellow oxid is given suspended in gum-arabic 
water, gr. 16 of the yellow oxid, gr. 20 of gum arabic, and dis- 
tilled water §j. Some prefer vaselin oil, but the gum solution 
is the least injurious. One grain is the usual dose. Lang's gray 
oil is made with vaselin. The parasiticide combinations have 
no real advantage, the effect being in proportion to the mercury 
contained in the salt. Other formulae are given in the Appendix. 
It is claimed that the insoluble salts have a more continuous 
action than the soluble salts, and that calomel is gradually con- 
verted into the perchlorid; but this is a source of danger, for 
if mercurialism sets in, no control can be exercised over further 
absorption. I would, therefore, never choose the insoluble salts. 

The symptoms, no doubt, often yield very rapidly to the injec- 
jection method, but its actual curative effects are not superior, 
relapses being just as frequent and severe, and indeed even more 
frequent,* as the injections are seldom tolerated long enough 
to prevent their occurrence. Besides necessitating frequent 
medical attendance, in spite of the denials of those who advo- 
cate them, the injections are more or less painful, and liable 
to produce inflammation, induration, or abscess, at the site of 
puncture. I would recommend any medical man who contem- 
plates subjecting his patient to this method of treatment, where 
the case is not urgent, or there are no special indications for it, 
to administer one or two injections to himself, and then follow 
the golden rule. They are also not altogether free from danger. 
A good many fatal cases have been reported. Runeberg re- 
ports a fatal result from the injection of one-grain doses of 
calomel, Kaposi had a fatal case from Lang's gray oil, and 
Hallopeau a case of frightful stomatitis; fat emboli in the lungs 
are also on record. 

These serious effects may, no doubt, be obviated in all but 
a very few hypersensitive persons, by sufficiently prolonging the 
interval between the injections and using only a small dose, 
not more than gr. 1-2 to gr. 1 of the yellow oxid, for instance; 
but there are still some minor inconveniences. The soluble 
salts may, however, certainly find a place where administration 
by the mouth or inunction is contra-indicated, in eye or severe 

* Marshall in 37 cases had 16 relapses, some bad; in 32 inunction cases 
there were only 7 relapses. 



892 DISEASES OF THE SKIN. 

throat lesions, in which it is important to get the patient rapidly 
under mercury, and it is a very convenient method for the public 
services, etc. 

Baccelli brought in the plan of intravenous injection. A solu- 
tion of perchlorid of mercury was injected directly into the vein 
of the forearm. The solution is, perchlorid of mercury one 
grain, chlorid of sodium three grains, boiled distilled water one 
thousand grains, a small quantity of alcohol may be added to 
facilitate solution; stir and filter. The mode of procedure is 
first to apply a ligature to the arm, as in bleeding, sterilize fine 
hypodermic needle, plunge it towards center of vein, and then 
direct it along lumen of vessel; allow a few drops of blood to 
ooze out to prove that the needle is in the lumen. Then apply 
the barrel, untie the ligature, and inject TT^xv of the solution.* 

There is no pain beyond the slight one of the needle prick, and 
the action on the lesions is very rapid. Thus Lewin f cured 
a case of rupia of two months' standing with six daily injec- 
tions and a gumma on the nose in one. On the other hand, 
thrombosis of the vein injected is very liable to occur, and peri- 
vascular exudation is still more frequent. The advocates deny 
the frequency of thrombosis, and say it is due to wounding the 
vessel; but I saw the treatment carried out by a most careful 
surgeon, and three veins became thrombosed in a very few 
injections. The treatment, therefore, must not be lightly under- 
taken, and it is only suitable where it is important to get the 
patient very rapidly under the influence of mercury, or, where he 
is intolerant of mercury, by other methods. It should not be 
used in out-patient practice, as the patient must be under close 
supervision. It has not been proved that the effects are more 
permanent, and that tertiary symptoms are avoided. 

Lastly, there is its administration by the mouth, which is, 
as a rule, the most practicable and convenient. The forms 
most employed by the mouth are hydrarg. c. creta and pil. hy- 
drargyri for the milder, and calomel, the perchlorid, the green 
and red iodids, and the bicyanid for the stronger preparations. 
Inasmuch as it is desirable that the patient should be kept more 

* Chopping reports eighty-four cases in which he used twenty minims 
of a one per cent, solution of the cyanid daily without any thrombosis. 
Easily controllable salivation occurred in two cases. 

\ Lancet, February 18, 1899. 



SYPHILIS. 893 

or less under the influence of mercury from one to two years, 
and sometimes longer, I prefer the mild preparations, which are 
efficient, and at the same time less likely to produce irritation 
of the alimentary canal, with griping and purging. One to three 
grains of gray powder, or blue pill, are given three times a day, 
guarded, when necessary, with two or three grains of Dover's 
powder, and continued till the eruptions or other symptoms are 
gone, and the patient begins to show evidence of the constitu- 
tional effects of the drug, such as slight salivation or tender- 
ness of the gums; the dose or frequency is then reduced, until 
the patient can just tolerate its influence without unpleasant 
effects. Frequent brushing of the teeth, and rinsing the mouth 
with alum and chlorate or permanganate of potash solution 
should always be enjoined, and the patient should smoke very 
little, or not at all. About every six weeks, a week or ten 
days' course of iodid of potassium, in three- to five-grain doses, 
three times a day, may be substituted for the mercury, in order 
to bring back into the system, in an active condition, the mercury 
which had become inert in the tissues. If, at the end of six 
months, the patient has been free from symptoms for two or 
three months, he might wait a month, go to the seaside or other 
invigorating climate, and then have another six weeks of mer- 
cury only. In this way a year may be spent, and if he still 
remains free, then he may have a six weeks' rest and a six 
weeks' mild course of mercury, to be followed by a week or two 
of iodid of potassium, and so on through another year; if still 
free, he might leave off treatment, watching carefully for any 
relapse, which must be the signal for the immediate resumption 
of mercury. 

All through the course the patient should guard against 
exposure to chills by wearing flannel next the skin, etc., 
keeping regular and early hours, avoiding sexual congress for 
his own and others' sake, and other excesses of all kinds, taking 
moderate exercise, and spending as much time in the country, or 
sea-air, as his circumstances permit. His diet should be gen- 
erous but digestible, and as for alcohol, the less the better as 
a rule, though claret and the lighter wines may be permitted 
sometimes. 

The green iodid. calomel and opium, etc., are preferred by 
many; they are valuable when it is important to get the patient 



894 DISEASES OF THE SKIN, 

under the influence of mercury in a short time, as in threatened 
iritis, when gr. 1-2 to gr. 1 of the green iodid, or calomel gr. 2, 
pulv. opii gr. 1-4, may be given every four hours. Otherwise, I 
prefer the mild preparations, as the green iodid is so liable to 
produce irritation of the alimentary canal, in consequence of 
which the drug may have to be suspended for a while, and 
valuable time is lost, besides that such irritation is more readily 
again excited, after it has once occurred. Moreover, in urgent 
cases intramuscular or intravenous injections might be em- 
ployed without damaging the digestive organs. 

In whatever way mercury is administered great care should 
be taken to avoid severe salivation; when large doses are being 
given the patient should be seen daily, and with smaller doses — 
until his tolerance, or intolerance, has been ascertained — he 
should be seen two or three times a week; at the same time, it 
is often necessary to push the drug up to the point of tender- 
ness of the gums or slight salivation. If from idiosyncrasy, or 
other cause, salivation occurs, the bowels should be freely 
opened with saline aperients, the mouth frequently washed out 
with chlorate of soda or potash gargles, and the soda salt taken 
internally in ten- or twenty-grain doses, and some give even 
larger doses. Iodid of potassium must not be given at first, for 
though it eliminates the mercury it brings what was inert and 
deposited in the tissues back into the circulation, and may thus 
aggravate the salivation to a dangerous degree. 

In the tertiary or relapsing stage mercury is often required, 
but it must be given in small doses, and generally with tonics ; 
the perchlorid gr. 1-32 to gr. 1-16, combined with three to five 
grains of iodid of potassium, forming the red iodid of mercury, 
which is dissolved by the excess of iodid of potassium, is one 
of the favorite combinations; it may be given with any bitter 
tonic, except cinchona. This combination, often called the mixed 
treatment, is by many given in the secondary stage also. This, 
in my opinion, is seldom a good plan, as the mercury is eliminated 
by the kidneys almost immediately after ingestion, and very 
often the symptoms return almost immediately after its being 
left off. Even in the tertiary stage, in which it is often most 
effectual in removing the lesion, a separate very mild course of 
mercurv is required subsequently. Reduced iron, gray powder, 
and chamomile extract, a grain of each, is also a good combina- 



SYPHILIS. 895 

tion. Only in visceral syphilis, with threatening symptoms, are 
the more vigorous methods of giving mercury required. 

Iodid of potassium, sodium, or ammonium have all their ad- 
vocates, but the potash salt is the one chiefly employed, on 
account of its great diffusibility, and is the salt referred to unless 
otherwise stated. It is useful in all stages, but in the secondary 
period is used by me only to wash the insoluble albuminate of 
mercury out of the tissues; many believe, however, that it is 
really curative. Some believe in combining the three iodids. 

In the tertiary period it is most valuable, on account of its 
wonderful capacity for procuring the disintegration and absorp- 
tion of gummatous growths or infiltrations, wherever they may 
be situated, but especially in bone. In the early stage three to 
five grains may be sufficient; in the later, five to ten grains 
are enough for most cases, but some people require larger doses 
before any effect is seen, twenty, thirty, even sixty grains freely 
diluted, three times a day, being given with benefit; but it is 
always wiser to begin with a moderate dose and increase it 
as far as may be necessary. Some patients, on the other hand, 
are very sensitive to its action, a few grains exciting severe 
headache, coryza, etc., so that the patients think the remedy 
worse than the disease; such patients may, however, be taught 
tolerance by beginning with one-eighth of a grain, and increas- 
ing by similar increments daily until a grain is attained to, and 
then adding a quarter of a grain to each dose till three to five 
grains are reached. Leistikow claims that in such cases iod- 
vasogen (six to ten per cent.) inunctions produce all the good 
effects of the iodids, and only rarely produce nasopharyngeal 
catarrh; forty-five grains may be rubbed in each day for three 
w T eeks. 

It is usually preferable to prescribe the iodid with bitter tonics, 
such as gentian, calumba, etc., and give it after food, to prevent 
disturbance of digestion. Carbonate of ammonia or sal-volatile 
is often prescribed with the idea that the action of the iodid is 
thereby increased and its tendency to produce coryza dimin- 
ished. I have, however, never seen any reason to believe that it 
does one or the other, but there is no harm in adding it. Bum- 
stead says that the chlorid of ammonium increases the action of 
the iodid if given in equal quantities, but it is a very nauseous 
salt. Belladonna and nux vomica are also said to prevent 



896 DISEASES OF THE SKIN. 

coryza, but their efficacy is not very great. Some of the gastric 
symptoms may, it is said, be avoided by giving the salt with 
maltine and pepsin wine. In some people its prolonged use 
produces gout, probably by setting up catarrh of the alimentary 
canal. I have sometimes found it necessary to prescribe a small 
dose of bicarbonate or citrate of potash with the iodid in such 
cases. The diminution in sexual power and appetite, produced 
by prolonged administration, can generally be overcome by gen- 
eral and local tonics after the omission of the iodid. The pre- 
vention and treatment of iodid eruptions are discussed else- 
where. 

It should always be borne in mind that, while the iodids act 
in the most gratifying manner in healing ulcers, removing in- 
filtrations and gummata, relieving pain or sleeplessness, etc., 
their effect seems to be exerted locally on the diseased products, 
while it has little or no power over the virus itself, so that the 
symptoms are only too apt to return sooner or later, when the 
iodid has ceased to be given; in other words, the disease is 
scotched, not killed, by iodin. Mercury, and mercury alone, 
aided by time and good hygiene, has any real curative influence. 

The iodids of sodium and ammonium are preferable some- 
times where large doses are required, as in large doses potash 
salts are very depressing to the heart; the ammonium salt should 
always be prescribed with carbonate of ammonia to prevent its 
too ready decomposition. Although they contain more iodin 
in proportion, on account of their different atomic weights, in 
other respects, on the whole, they are less efficacious. Rarer 
salts, such as the iodids of strontium, lithium, calcium, and 
rubidium, have had their advocates, but the only one of any 
real value is the rubidium salt, which is said to be nearly or 
quite as good as the potassium iodid and better tolerated. 

Larrieu's method is to give three minims of tincture of iodin 
with fifteen grains of iodid of potassium in a half a tumbler of 
water every morning before breakfast. It has the advantage 
of freeing the patient from medicine-taking for the rest of the 
day. I have found it useful in the tertiary stage, but he uses 
it at all stages without mercury, unless there is iritis or other 
urgent symptoms. 

A general tonic treatment is frequently necessary at all stages 
of the disease. Sometimes iron may be combined with the 



SYPHILIS. 897 

specifics, e. g., the syrup of the iodid of iron; cod-liver oil, with 
or without iodin, is also often necessary. Sometimes it is best 
to suspend the specifics and give the mineral acids and nux 
vomica or cinchona, quinine and iron, etc. It is instructive, 
sometimes, to notice how, when specifics fail to exert their 
wonted influence, after a course of tonics, a sojourn at the sea- 
side or in the country, or careful feeding up of a badly nour- 
ished patient, the mercury or iodid again becomes efficacious. 

Iodipin is another form of giving iodin for which good results 
are claimed. It is made in ten and twenty-five per cent, strength 
dissolved in sesame-oil; 5j to oiv of the ten per cent, solution 
may be given three times a day either in capsules or in hot 
milk. It may also be injected into the buttock, a Pravaz 
syringeful with a large nozzle being required. 

The local treatment of syphilids, though frequently unneces- 
sary, generally hastens their disappearance, and may be essential 
to effect it. When they are extensive, the calomel vapor-baths, 
already described, are the best means of getting at them. For 
the superficially ulcerated throat, a perchlorid of mercury gargle 
two to four grains to gviij of distilled water, used three or four 
times a day, soon produces improvement; or calomel may be 
applied by local volatilization, or, what is quite as good, and 
simpler, by connecting a glass tube containing the calomel to 
an india-rubber ball and puffing it on. Mucous tubercles also 
soon yield to the local application of calomel, or a slight applica- 
tion of sulphate of copper or of the stick of nitrate of silver 
sometimes hastens their departure, as well as that of superficial 
ulcerations, but it should be only sparingly resorted to. The 
parts should be washed two or three times a day with a 1 to 1000 
corrosive sublimate solution, and the adjacent surfaces separated 
by absorbent or iodoform wool. Ulcerations, whether sec- 
ondary or tertiary, may be cleaned up and healed, by local 
calomel fumigations, by dusting on iodoform or iodol two or 
three times a week, and using black or yellow wash on lint cut 
to the size of the sore and covered with oiled silk. When, as 
in rupia, they are too numerous, or in awkward positions to 
keep on dressings, iodid of starch paste, recently made and 
painted on, generally induces them to heal in a kindly way. I 
have found it a very convenient and effectual plan for both rupial 
and tertiary gummatous ulcers to pack each ulcer with alem- 
57 



898 DISEASES OF THE SKIN. 

broth wool night and morning; foul ulcers clean up and form 
healthy granulations very rapidly, and where the ulcers are nu- 
merous the facility of application adds to its value. 

Nodules or infiltrations of the skin, whether secondary or 
tertiary, may be treated by rubbing in gently unguentum 
hydrargyri, either pure, or diluted if there is much hyperemia. 
Oleate of mercury two to ten per cent, is more cleanly than 
the ung. hydrarg.; the mercurous salt is the more efficacious, 
and should be made by chemical combination. Mercurial plas- 
ters are also convenient and efficacious; the emplastrum hy- 
drargyri of the English or German Pharmacopeia, Beiersdorf s 
paraplast of fifty per cent, mercury and 7.5 per cent, carbolic 
acid, and the emplastrum Vigo of the French, are good exam- 
ples of these plasters. They may also be used round ulcers 
packed with alembroth wool as above. Hypodermic injection 
of one or two grains of iodid of potassium, in a dilute watery 
solution beneath the lesion, acts very rapidly, but is rather 
painful. 

Eruptions on the face are a great trouble to the patient; for 
these the weaker preparations of mercury are generally pref- 
erable, the ammoniated mercury ointment twenty grains to the 
ounce, the oleate of mercury one or two per cent., and some- 
times at night, the diluted nitrate or ung. hydrarg. When there 
is much hyperemia, it is often desirable to commence with ordi- 
nary astringents, such as calamin lotion, as in such cases the 
mercurials may be too stimulating at first. Rhagades at the 
mouth or nostrils yield to painting with hyd. oxid. flav. gr. 10 
to adipis 5J, or to the calomel cream of the Lock Hospital, 
calomel 5j, oleum olivae oij. 

The obstinate palmar and plantar syphilids of the tertiary 
stage become amenable to treatment, if the thickened epidermis 
be first removed; it may be done by rubbing it down with 
pumice stone, a corn rubber, or glass paper, or by the applica- 
tion for several days of Unna's salicylic plaster; ung. hydrarg. 
should be subsequently rubbed in. Some use a potash lotion for 
the same purpose, but if there are any fissures it is very painful. 
On the soles, where the horny cuticle is often very thick, it may 
be first shaved down with a razor, but without this preliminary 
the treatment is very unsatisfactory. The fissures, ulcers, white 
patches (leukoplakia), etc., of the tongue often give great 



SYPHILIS. 899 

trouble in the relapsing period. All sources of irritation, such 
as smoking, the use of condiments, etc., should be interdicted, 
and irregular or tartar-covered teeth removed. The mouth 
should be washed out with weak Condy's fluid when the teeth 
are cleaned, which should not be less than twice a day, and then 
a two or three per cent, solution of chromic acid should be 
painted on daily; this generally gives great relief, and is not very 
disagreeable. Less pleasant, but useful in obstinate cases, is 
a one to three per cent, perchlorid of mercury solution, but the 
brush must not be dipped directly into the bottle, or the solu- 
tion soon gets inert. In severe cases Hutchinson's plan of 
painting on the strong acid nitrate of mercury, though painful 
at the time, will give relief for a month or two, and does not 
require to be used more than once in three months. 

In tertiary syphilis the large part played by local irritation 
in producing the lesions must be borne in mind, and as far as 
possible means must be adopted to prevent such irritation. 

In congenital syphilis inunction of ung. hydrarg. is generally 
the best method; a piece of ointment the size of the end of the 
finger should be rubbed on the flannel binder daily, and the 
child's movements work it in, the position for its application 
being changed from time to time, to prevent local irritation. 
This treatment may be continued until all symptoms have dis- 
appeared, and for a month or two longer, but with diminished 
quantity; cod-liver oil, with or without maltine, and steel wine 
or other form of iron, are often necessary adjuncts. After the 
mercury has been left off, syrup of the iodid of iron is a suitable 
tonic. The child should be kept under observation for a least 
twelve months. Where there is much skin eruption, the oint- 
ment cannot always be applied, and then a grain of hydrarg. 
c. creta can be given three times a day to the youngest infant, 
and if, after some time, diarrhea is produced, some pulv. cretse 
comp. may be given with it, but this is seldom necessary. The 
erythema of the buttocks is best treated by dusting on oss to 5j of 
calomel to §j of starch powder. To the condylomata, or mucous 
tubercles, a little pure calomel may be applied, paying great at- 
tention to cleanliness, and keeping the parts as dry as possible; 
changing wet napkins at once is of course necessary. 'The nos- 
trils must be frequently cleared out, and if the child cannot suck 
well it should be fed with a spoon without delav. Careful atten- 



900 



DISEASES OF THE SKIN. 



tion to hygiene in every way is highly important. Except in 
the way already indicated, local treatment is seldom required 
for the skin lesions, the effect of the internal administration of 
mercury being almost magical in the majority of cases, unless 
treatment has been too long delayed, so that the nutrition has 
already suffered considerably; indeed, as a rule,. the prognosis 
is good or bad in proportion to the nutrition of the child when 
it first comes under treatment. 

LEPRA.* 

Deriv. — hen pa, leprosy. 

Synonyms. — Leprosy; Elephantiasis grsecorum; Leontiasis; Saty- 
riasis. Fr., La lepre; Gcr., Der Aussatz; Norweg., Spe- 
dalskhed. 

Definition. — An endemic, chronic, constitutional disease analo- 
gous to syphilis, and varying in its morbid manifestations, ac- 
cording to whether the brunt of the disease falls on the skin, 
nerves, or other tissues. 

Leprosy has ceased to be one of the diseases of England f 
since the sixteenth century, and is now met with here only as 
an importation ; but it is still rife in Norway, and to a less extent 
on the shore of the Baltic, and of late years in Russia; it is 
said to be spreading in the south of France and Spain, and it is 
frequent on the northern littoral of the Mediterranean, Turkey, 
Roumania, and the whole Balkan peninsula, and some other 
parts of Europe. Many instances of its different forms have 

* Literature. — Danielssen and Boeck. "Traite de la Spedalskhed " 
(Paris, 1848. French translation). Vandyke Carter on Leprosy and 
Elephantiasis (1874). Hillis, " Leprosy in British Guiana" (1881). Leloir, 
"Traite de la Lepre" (Paris, 1886). Thin, "Leprosy" (1891), a resume 
in 280 pages. The Journal of the Leprosy Committee. " Leprosy in its 
Clinical and Pathological Aspects," by Hansen and Looft. Translated by 
Norman Walker, 1895. Five clinical and eight microscopical plates. 
Trans. Berlin Leprosy Co)iference, 1897. The Lntemational Journal, 
Lepra, vols. i. and ii. Babes, "Die Lepra" (1901), and Santon, "La 
Leprose" (rgoi), with illustration and plates. 

fin Lancet, September 16, 1899, Dr. Ross McMahon records a case of 
a man who had never been out of England, but such a case would require 
to be reported on by experts before it could be unreservedly accepted. 



LEPRA. 901 

come under my care at various times, but it is only from those 
who have long studied the disease in its native haunts — such 
as Danielssen and Boeck, and Hansen in Norway, Vandyke 
Carter in India, and Hillis and Beaven Rake in the West Indies — 
that we can glean a complete account of its numerous mani- 
festations, and in the following description I have followed those 
writers, especially Hillis, pointing out where my experience dif- 
fers from theirs. 

The disease occurs in three forms — the Nodular, the Maculo- 
anesthetic, and the Mixed.* The nodular is the most common 
in Europe, the macuio-anesthetic in the tropics, and the mixed 
is nearly always less common than either of the others. Al- 
though they form a pathological unity, these varieties are so 
distinct clinically as to require separate description. In the 
nodular form the brunt of the disease falls upon the skin; in 
the macuio-anesthetic, on the nerve trunks, and in the mixed, 
on both nearly equally. 

In advanced cases the tendency in a large proportion is to 
merge into one another. 

Nodular Lepra constitutes over fifty per cent. (Kaurin says 
seventy per cent.) of the cases in Norway, about twenty per cent, 
in the West Indies, and not more than ten per cent, in the East 
Indies. No less than five stages may be recognized: first, de- 
posit with prodromata and fever; second, eruption; third, nodu- 
lation; fourth, anesthesia (not constant); fifth, ulceration. The 
prodromata which nearly always attend the onset are of the fol- 
lowing kind: debility, depression, dyspepsia, diarrhea and drowsi- 
ness, listlessness, a frequent sense of chilliness, especially at 
night, profuse perspirations and marked vertigo, temporarily re- 
lieved by recurrent epistaxis. Then, perhaps, after a chill or 
other depressing influence the febrile symptoms set in. 

Their onset is marked by a rigor, and a temperature which 
may rise to 104 . The pyrexia is of a remittent, an inter- 
mittent, or rarely of a continuous type, and is often mistaken 
for ague; the drowsiness and sweating become more marked, 
the patient feels restless, the tongue is red, the pupils sluggish, 

* These correspond with the terms in previous editions of tuberculated, 
non-tuberculated, and mixed tuberculated of Hillis; the two first terms 
are those of Hansen. 



9 02 DISEASES OF THE SKIN. 

and the pulse quick and feeble. These febrile symptoms may 
set in abruptly without any prodromata, it may be, several 
months or even years after exposure to the leprous influence. 
After they have lasted for a variable period of days, weeks, or 
months, the exanthem or " leprous spot " appears, coining 
first with edema of the eyelids, on the prominent parts of the 
face and ears, and then on the limbs, occupying the front of the 
forearms and the outside of the thighs. The eruption is of an 
erythematous character, varying from a bright to a purplish or 
mahogany red tint in fair people, and there is leprous deposit, 
not mere hyperemia, from the first. It is in well-defined, 
shiny, slightly raised patches, of from one to several inches in 
diameter, and distinctly hyperesthetic; these patches may fade 
to an orange tint or altogether disappear and reappear after an 
interval, each time with febrile symptoms, and this may go on 
for weeks or months before the next stage of nodulation sets 
in, or they may be persistent, becoming more conspicuous if 
the patient gets warm.* 

In a young lady, aet. fourteen, they were very bright, and the 
forehead and chin were something like an erythema nodosum 
in the wrong place, but they had been out several months. The 
disease began with symptoms supposed to be due to rheumatic 
fever seven years after she left Ceylon, she having been quite 
well in the interval. On the other hand, there may be a total 
absence of general symptoms, not only when the skin eruptions 
are of very slow development, but even when the eruption 
comes out somewhat acutely. Thus, in a boy of seven from 
British Guiana, who had been perfectly well until six weeks 
before I saw him, a red patch came out on the left cheek one 
inch across, then the right ear became red and swollen and 
shapeless, and other lesions appeared in various parts of the 
trunk and limbs. The boy had not been, and was not when I 
saw him, unwell in any way whatever, and was bright and 

* Francis S., set. fourteen, U. C. H., born of healthy Scotch parents in 
the West Indies; while there he had repeated attacks of what were con- 
sidered to be erysipelas of the right leg going on for seven years, and it 
was not until he had been six months in England that nodulation set in, 
after a severe rigor and febrile symptoms of a few days' duration, but 
with no erythematous eruption, the first nodules appearing on the site of 
a recent burn on the heel. The subsequent course was very much the 
same as above described. 



LEPRA. 9 o 3 

lively. I have seen diffuse erythema over the face and greater 
part of the body. 

After the first, or one of the subsequent exanthematous 
attacks subsides, the eruption fades, crops of minute pink eleva- 
tions, grouped or scattered, appear on the site of the previous 
rash, the papules enlarge to the size of a split pea, and form 
yellowish-brown nodules, and some of these may enlarge much 
more, even to the size of a hen's Qgg, or they may gradually 
coalesce into a diffuse infiltration, or the infiltration may be 
produced directly, by the erythematous patch thickening instead 
of resolving, and may thus form regular plateaus of large size, 
and, like the nodules, of yellowish to dark brown color. In 
fair races, when the disease is of moderate severity, ovals or 
circles with broad borders and clear white centers may arise, 
and fresh nodules may also develop on the infiltrations. As 
a rule, nodulation does not develop until from three to six 
months after the commencement of the disease; as the nodules 
and infiltrations become fully developed, the hyperesthesia sub- 
sides, and may be replaced by diminished sensibility or even 
complete anesthesia, if the infiltration is considerable, simply 
from pressure of the leprous material on the peripheral ends of 
the nerves. Nodules may come anywhere, but they are most 
common on the face, limbs, breasts, scrotum and penis, round 
the arms and in the axillae, but are rare on the back, neck, soles 
and palms, and still more so on the elbows and knees, while they 
are said never to occur on the scalp * and glans penis. f The 
mucous membranes also get involved, including those of the 
eyes, nose, mouth, and tongue, larynx, trachea and large 
bronchi, uterus and vagina. The fate of the nodules and in- 
filtrations varies; some resolve and leave only stains, others 
atrophy, but leave atrophic scarring, while others again soften, 
break down, and ulcerate, forming indolent, sharply defined, 
red-glazed sores with yellow " glairy mucous discharge of pecu- 
liar odor," which at first can be healed with appropriate treat- 
ment, but not as the disease becomes advanced. When the dis- 

* In John C. N., U. C. H., a mixed case, there were a few nodules on 
the scalp; in Evan S., U. C. H., there were one or two on the palms. 
References to other palmar cases are given in a paper by Montgomery, 
Amer. Jour. Cut. and Gen.-Ur. Dz's., vol. xvi. (1890), October No. 

f Gliick has seen nodules and flat infiltration on the glans penis in ten 
cut of forty cases, Lepra, vol. i. (1900), p. 10. 



904 DISEASES OF THE SKIN. 

ease is fully developed, the face gets the characteristic leonine 
appearance from the thickening of the skin between the natural 
wrinkles of the forehead, which thus appear deepened, and give 
a stern and aged look even to children; the cheeks, unless the 
nodules remain discrete, look enormously puffed out and 
pendulous, and the skin is very soft and satin-like; the lips 
are swollen and everted, and with the nose and chin are 
covered with nodules; the ears project conspicuously, are 
often, even at an early stage; much thickened and covered 
with nodules, and the lobe especially is very large, soft, and 
pendulous, and may be the only part of the ear attacked; the 
hair is preserved on the scalp, but is lost elsewhere; the nails 
are thin and papery, split, flake, and drop off, sometimes to be 
renewed in the shape of horny pegs, but they may recover 
completely. 

A somewhat different picture is presented in many cases in 
which nodulation is a late manifestation, there being simply 
a uniform infiltration deepening the natural lines, but the sur- 
face is otherwise smooth. In white people there is a yellowish- 
brown tint, or in cold weather a slate-colored lividity. Nodules 
appear eventually. 

In males the testicles atrophy, the breasts enlarge, and 
sexual power is lost; women become sterile; the voice gets 
croaking from nodules in the larynx, there is snuffling from 
thickening of the nasal mucous membrane, a kind of pannus 
may ensue on the conjunctiva and cornea, and interstitial 
keratitis and corneal nodules, and, still worse, a chronic irido- 
cyclitis may lead to blindness.* Dr. Lie has found lepra 
bacilli in almost all the structures of the eye, even in an appar- 
ently cured maculo-anesthetic case. 

From time to time exacerbations occur, with enlargement of 
the lymphatic glands, especially the femoral, and febrile symp- 
toms of the same character as before; and after each attack 

* For a full account of the eye changes, see Bull and Hansen, " The 
Leprous Diseases of the Eye " (translation, with colored plates, published 
in London, 1873), and " Leprosy as a Cause of Blindness," C. F. Pollock 
(Churchill, 1889). " Die Lepra des Auges," by Syder Borthen, with 
"Pathology" by H. P. Lie, published by W. Engelraann, Leipzig, 1899. 
Also " Notes on Ocular Leprosy," by A. Neve, Brit. Med. Jour., May 12, 
1900, who reports lesions of lids, conjunctiva, cornea, iris, and globe, but 
not the lens, in Kashmir Asylum. 



LEPRA. 905 

fresh nodules are formed. Acute orchitis occurred in a case 
of Hallopeau's. These attacks occur about four times a year, at 
the change of the seasons, in the tropics (Hillis),* but less fre- 
quently in colder climates, and are the milestones on the down- 
ward road. Ulceration eventually sets in, at first only in single 
nodules and spreading slowly, but sometimes it is phagedenic 
and rapid, and in either case enormous areas may get involved 
and lead to the death of the patient by exhaustion, or death 
may ensue from interference with the air passages or from other 
internal deposits. Forty per cent, perish from the direct effects 
of leprosy, while another forty per cent, die from renal and 
lung complications, and the rest from diarrhea, anemia, etc. 
The mutilations of the maculo-anesthetic form are never pres- 
ent in this. 

In the dark races the " leprous spot " is a bright red, the 
sweatings are accompanied with oiliness, and the skin is always 
very greasy, with dilated sebaceous openings. The nodules at 
first are translucent and quite solid, but eventually get blacker 
even than the black skin that they are on; this is true also of 
the involuted erythematous exanthem. The surface is very 
scaly, sometimes so much so as to mask the disease. In ad- 
vanced cases Hillis describes a peculiar mottling, like a richly 
grained wood, on the belly, and mapping out the spinal cord 
behind. 

In a large proportion of cases there are comparatively few 
lesions on the trunk even in advanced cases, the face and limbs 
being chiefly affected. 

Variations. — It must be borne in mind that skin lesions may 
develop without any prodromal manifestations, either acutely 
or slowly and insidiously. Thus a man on the Zambesi was 
quite well until he had a sunburn on the shoulder from a hole 
in his shirt; the next day red spots broke out all over his body 
and limbs, and increased till he was a uniform red color. This 
was soon followed by great pains in the feet, and the disease 
developed on the usual lines, but it was a year before the fea- 
tures thickened very noticeably. In a gentleman who had 
contracted the disease in India three years before the sole mani- 
festations were yellowish-brown slightly raised, hemp-seed to 

*Some of my cases have had intervals of several years between the 
febrile exacerbations. 



9 o6 DISEASES OF THE SKIN. 

large pea-sized papules, rather numerous on the trunk and 
limbs. He had not been in any way different from his usual 
health, and there were no sensory symptoms before or follow- 
ing the eruption. Three years later also there were no fresh 
symptoms beyond an increase of the skin lesions; a few months 
later most of the eruptions had disappeared. 

In a boy of seven from British Guiana a red raised patch on 
the left cheek was the first sign without any general symptoms. 
Other red patches developed rapidly, but without disturbing 
the general health. 

In other cases, again, there may be one or two nodular 
lesions which have developed slowly without any other symp- 
toms for months or years. In a case of Pelizzari's, the only 
lesion was an achromic area surrounded by a pigmented area 
on the right arm. Hansen's bacillus was found. 

In children small nodules come comparatively early on the 
alse nasi and lips. 

When there is an hereditary taint, Hillis has observed " that 
sores or abrasions become indolent and unhealthy, general dis- 
eases are less amenable to treatment, and in the black races 
the skin is scaly, shiny, and variegated, the lymphatic glands 
are enlarged, and the patient has a cachectic look, the features 
are coarse and unsymmetrical, the head looks too large for the 
body, the functions are imperfectly performed, and the skin has 
a peculiar soapy feel, while mentally the patients are dull, list- 
less, and apathetic." Voight * made a careful examination of 
the tissues of a child of five weeks, who was born in a leper 
asylum of leprous parents, and found no bacilli or other leprous 
changes in the skin or other organs. 

The disease comes out in such cases before they are twenty, 
generally from ten to twenty, but rarely under three years of 
age, very few, if any, under twelve months, and there are only 
one or two more than doubtful instances on record, of the 
infant being born with it. The absence of congenital cases will 
be discussed under heredity. But Danielssen and Boeck record 
that the parents of some affected children have stated that they 
were born with bluish spots, on which nodules subsequently 
developed. 

* Vratch xx. (1899), p. 485. Abs. Amer. Jour. Cut. Dz's., vol. xvii. 
(1899), p. 323. 



LEPRA. 9 o 7 

Maculo-Anesthetic Lepra is the most common tropical form, 
constituting two-thirds, while in Norway it is only one-third, 
of all the cases. 

Three stages may be recognized in the course of the disease, 
but they may be ill-defined in some cases: (i) that of develop- 
ment; (2) of spreading; and (3) of permanency. The first lasts 
one or two years, and includes the prodromata, the eruption, 
and the commencement of atrophy. The prodromata differ 
much from those of the nodular form. Febrile symptoms are 
absent, but a frequent sense of chilliness, especially towards 
evening, is experienced; malaise, and perhaps gastric and cir- 
culatory disturbances, may be present. But the most char- 
acteristic symptoms are pain and tenderness in various places, 
a general hyperesthesia of the skin, and shooting, lancinating 
pains, compared to electric shocks, which traverse certain 
nerves, especially the ulnar, the median, the peroneal, and the 
saphenous, accompanied by a burning sensation, and tender- 
ness along their course.* In a gentleman, set. thirty-two, from 
Jamaica, the first symptom, four years before, was intense itch- 
ing between the toes, and soon after brown spots appeared on 
the leg. In the same way, the involvement of other nerves 
was marked by severe itching, followed by numbness, but he 
never had pain, but felt pricking and " pins and needles " down 
the limb when the peroneal or ulnar nerves were tapped. 
Drowsiness, lassitude, and depression were the only general 
symptoms. Weakness of grasp and numbness in the course of 
the nerve are early symptoms, and the ulnar is generally the first 

* In the case of a boy, J. H., E. L. H., the symptoms began at the age 
of four years, in Suffolk, apparently with an attack of ague, eight months 
after his leaving Singapore. The eruption preceded by a very short 
interval the nerve symptoms, which commenced with numbness and 
weakness of grasp; but there were no pains nor early bullous eruption, 
and in about twelve months his ulnar nerves were completely paralyzed, 
and the median partially. Subsequently complete paralysis of the hands 
developed, and the fingers were clawed. Bullae came in cold weather, 
and the characteristic, peripherally spreading eruption appeared, preceded 
by an erythematous exanthem; but there was only diminution of sensi- 
bility in the atrophic area. In this case the ulnar nerves, which were 
much thickened, were stretched without effect. He was under observation 
for six years, and died, set. thirteen, in the hospital with pyemia and 
ulcerative endocarditis; but this did not appear to be dependent upon the 
leprosy, as he had been exposed to septic influences. 



9 o8 DISEASES OF THE SKIN. 

to suffer, the peroneal being the next commonest. There may 
be loss of sensation to pain, touch, heat, and cold, or tactile 
sensation may be preserved and heat, cold, and pain lost, as 
in syringomyelia, which may be simulated, or perhaps pro- 
duced.* According to Susuki, the tendon reflexes are exag- 
gerated in anesthetic leprosy. Numerous small bullae often de- 
velop on the fingers and toes in association with the shooting 
pains, and occasionally the condition known as " glossy skin " 
may supervene with the characteristic burning pain. 

Within a year the more special eruption breaks out, the most 
frequent positions being the back, shoulders, back of the arms, 
neck, thighs, round the knees and elbows, on the face and 
sometimes in the course of nerves, especially the musculo- 
spiral; they are very rare on the palms and soles. f The spots 
or patches come out singly as a rule, are one or two inches in 
diameter, well defined, but not raised, and of a pale yellow 
color. They may itch or burn, but are not always hyperesthetic, 
though Hansen usually found them so, and rarely anesthetic at 
this stage; but the sweat secretion is absent in them. Fresh 
patches continue to come out from time to time, but unat- 
tended with special symptoms. Sometimes some of the muscles 
waste, and there is contraction of the little finger, while sensa- 
tion in the course of the' affected nerve is diminished by this 
time if it has not been before, and thus the second, or spread- 
ing stage, is reached in a year or two from the commencement. 

With the exception of those on the neck the patches spread 
peripherally, clearing in the center and forming irregular ovals 
or circles, or meeting with others, inclose large, gyrately 
margined tracts. The border is now distinctly raised, hyper- 
sensitive, from an eighth to half an inch across, of a yellowish- 
brown color, and made up of closely aggregated papules which 
have coalesced more or less, or there may be minute vesicles on 
them at the edges. The center is atrophic, preternaturally 
white, thin, wrinkled, hairless, scarlike, and dry from the de- 
struction of sweat glands, and hence, later on, a powdery des- 
quamation is observed. 

Anesthesia is nearly always present in the atrophic patches 

* In a case reported by Hallopeau and Jeanselme these symptoms 
appeared during an intense erythrodermic attack. 

f Montgomery, loc. cit., one case, and quotes two of Von Bergman's. 



LEPRA. 909 

as well as in the course of the affected nerves, and slowly ex- 
tends its area; as a consequence, the patient often gets burns and 
other injuries unconsciously, and perforating nicer of the foot, 
starting from a slight injury, may ensue, but it is most common 
in those who walk barefoot. Another result of the paralysis of 
the nerve function is the formation of solitary, large bullae on 
the extremities. They arise mostly in cold weather, or from 
some local injury, and leave a very indolent ulcer. They differ 
from the early bullae, therefore, in size, number, and cause, the 
early ones being due to an irritative, the late, consequent on 
a paralytic condition of the nerve. Fissures of the heel are also 
common, and dark-colored hyperkeratoses may be seen sym- 
metrically on the front of the legs or back of the hands (Han- 
sen). The diseased nerves can be felt to be thickened, espe- 
cially the ulnar at the elbow.* 

Paralysis is usually a late symptom, and produces flexion of 
the second and third phalangeal joints, but the first remain 
straight, much wasting of the muscles and wrist-drop ensue, 
and nutrition of the nails is damaged so that they become like 
talons; next interstitial absorption of the bones takes place, or 
a larger necrosis may occur, leaving the nail still attached to the 
stump (the so-called lepra mutilans. The carpal bones are 
seldom destroyed). Sleeplessness is sometimes a trying symp- 
tom, but otherwise the general health suffers comparatively 
little, and much of the lost strength may be regained for some 
time when the permanent stage is reached, which is generally in 
about ten years. 

The eruption now remains stationary, though by this time 
nearly all the body surface may have been traversed by it, so 
that the whole skin is atrophied and white. Other nerves, such 
as the third and seventh, may be paralyzed, and ectropion and 
the other consequences of these paralyses ensue, or some mus- 
cles of the leg may be paralyzed. 

Ulcerations are common, but less extensive than in the 
nodular cases, though they are often deeper, either from moist 
or dry gangrene, which spreads until it reaches a joint; a line 
of demarcation is then formed, and nature performs amputa- 
tion, often very neatly. Although this may be repeated from 
time to time, the process is slow and not extensive on each oc- 
* See J. H's case, in previous note. 



9 io DISEASES OF THE SKIN. 

casion, so that the patient's strength is wonderfully preserved, 
and the sexual power is retained up to a very late period. 
Ultimately, however, the constitution is undermined, and he suc- 
cumbs from various causes. 

Death occurs in two-fifths of the cases from the direct effects 
of leprosy, such as ulceration, gangrene, marasmus, or general 
debility, induced by the leprosy poison. Muco-enteritis ac- 
counts for nearly as many, and the rest die from various com- 
plications, but nephritis is not a special cause, as in the nodular 
form, and probably the muco-enteritis is largely climatic. 
Cases usually last from ten to fifteen years, though life may be 
prolonged for thirty or even forty. In some of these the dis- 
ease has really died out, the skin lesions having disappeared, 
and only the results of the nerve damage left. 

In negroes the eruption is of a bright yellow, and is much 
more conspicuous from the contrast with the dark skin; the 
vesicles that border the edge of the eruption in the spreading- 
stage are also more distinct, and when the eruption has 
traversed a large extent of surface the atrophy of the pig- 
mented part of the skin is much more striking than in the fair 
races. 

In children, unless the manifestations of leprous cachexia men- 
tioned by Hillis are present, there is no special difference in the 
maculo-anesthetic cases from those of adults. 

Variations. — In the maculo-anesthetic form the insidious 
development of skin lesions without other symptoms is more 
common even than in the nodular form. Pigmentary anom- 
alies, either plus or minus, may be the earliest symptoms, and 
according to Hansen and Looft the skin affection is always the 
first definite symptom of the disease, but this is not in accord- 
ance with the observations of others. A woman, set. thirty-six, 
who had traveled in India for a year, eighteen months later 
developed rings on the left thigh and forearm. The lesions were 
round or oval, one to three inches in diameter, with a raised 
brownish-red border, a quarter of an inch wide, and a slightly 
papular irregular outline; the center was faintly atrophically 
scarred, and there appeared to be slight diminution of sensi- 
bility. There were only half a dozen such lesions, and no other 
manifestation of any kind; during six months that she was 
under observation a few fresh rings slowly appeared, but two 



LEPRA. 911 

years later all had disappeared again. Nerve trunk symptoms 
may or may not develop later. In a boy of sixteen, the sole 
lesion was a perforating ulcer of a big toe, and anesthesia of 
a great part of the left foot. This had been going on for two 
years. Mutilating whitlows with anesthesia may also occur, 
and if Zambaco Pacha's views be accepted, Morvan's disease 
as seen in Brittany is only attenuated leprosy. There are, how- 
ever, a few cases of indisputable leprosy in Brittany, but the 
long yearly visits of the fishermen to Iceland must be remem- 
bered as a probable source of the disease; but Jeanselme re- 
ports a case he believes to be autochthonous. 

Mixed Lepra is the least common form, constituting about 
one-sixth of all cases; about half are hereditary according to 
Hillis, and often each parent has had a different form. In 
British Guiana, however, Hillis found in 188 cases the follow- 
ing proportions: nodular, two; mixed, three; maculo-anesthetic, 
six. It begins sometimes with nodular and sometimes with 
maculo-anesthetic symptoms, but most frequently the latter 
symptoms take the lead for a few months, and then with fever 
and the usual phenomena, nodulation occurs. Destruction of 
the cartilages of the nose sometimes ensues; the soft palate also 
may be destroyed by ulceration, and constitutes special features 
of this form. For the rest, the symptoms are a compound of 
the other two varieties. 

The prognosis is bad, and if nodulation precedes the anes- 
thetic symptoms the progress is more rapid. 

The diagnosis requires care sometimes, to distinguish it from 
syphilis, but the presence of anesthesia will be a certain 
criterion. 

The following is a good example of its mode of onset and 
course: 

John C. N., set. twenty-two, came to University College Hos- 
pital in January, 1885. He was born in Bombay of healthy, well- 
to-do English parents; he was suckled one month by a native 
nurse, and lived in Bombay until he was sixteen years old. 
He ate fish, but it was always quite fresh. The disease began 
in October, 1879, eighteen months after his return to England, 
after sitting in wet clothes for three hours, with vomiting, great 
pain, and swelling of the limbs, ascribed to rheumatism, soon 



912 



DISEASES OF THE SKIN. 



followed by severe shooting pains down the arms and legs, and 
great depression, and these pains continued more or less for 
two years, when he returned to India. Eighteen months later 
an infiltrated patch appeared, with pain and swelling on the 
right calf; anesthesia in the left forearm and calf developed in 
1882; next a brown patch came on the low^r jaw, and in 1883 
nodules appeared on the ears, and later on the face and scalp. 
The disease after this progressed in the usual course; phthisis 
developed in the beginning of 1886, and he died with general 
tuberculosis in September of that year. 

Etiology. — This must be considered as regards its production 
and propagation. 

Concerning production, neither climate, soil, race, malaria, diet, 
bad hygiene, nor antecedent diseases, such as syphilis, yaws, 
or ague, can be regarded as anything more than predisposing 
influences, which favor its onset and development, mainly by 
lowering general vitality, and therefore resistance to disease. 

As regards climate, while it is certainly most prevalent in 
tropical and subtropical countries, it frequently occurs also in 
cold climates, such as Norway, New Brunswick, and Iceland; 
in short, it may be found from the poles to the equator, and 
from the east to the west. Climate seems, however, to have 
an influence on the form of the disease, as nodular leprosy is 
most common in Europe, probably from the influence of cold 
checking the skin action, and non-nodular in warmer climates. 

As for soil, it may occur in high or marshy lands, in town or 
country, by rivers or seas; and though it is true in the main 
that the home of leprosy is in the vicinity of water, even this 
must not be said without reservation. 

Eating fish, especially if salt or unsound, is supposed by some 
high authorities to be the cause of leprosy, the idea having 
probably arisen from fish being a staple article of diet in tropi- 
cal and subtropical countries where leprosy is endemic; but, 
since in many countries, where, either from religious prejudices 
or other circumstances, no fish is eaten, yet leprosy is rife, this 
theory must be regarded as untenable as the sole cause, though 
if it should turn out, as many suppose, that an intermediary 
host is required before the bacillus will flourish in the human 
subject, it would be natural to turn to the food or the water 
to find the intermediary. 



LEPRA. 



913 



Propagation. — Intermarriage plays a certain part, and in some 
places, such as the Cape, Provence, Austria, and Galicia, 
leprosy is limited to certain families which intermarry. 

Heredity was considered, until lately, to have an undoubted 
influence, but most modern authorities dispute its claim to be 
considered as a factor. Hansen of Norway visited the Nor- 
wegian emigrants in America, in some parts of which they form 
a community, and could not find a single instance of heredi- 
tary influence, and he and others account for the family preva- 
lence from the children and parents dwelling together in close 
relationship and under the same circumstances; in short, they 
consider it is a household, not a family disease, and is propa- 
gated by contagion therefore. Heredity was never considered 
to be an important factor as regards numbers. D. Mont- 
gomery's cases in a leper family show the sources of fallacy in 
apparent heredity. 

Contagion* — The question whether leprosy is contagious or 
not was answered by the College of Physicians' Report of 
1867, and that of the Hawaiian Government in 1886, in the 
negative, while the majority of the recent Leprosy Commission, 
while admitting that it is contagious and inoculable, consider 
that contagion plays a very small part in its extension. On 
the other hand, the Conference on Leprosy held in Berlin in 
October, 1897, not only agreed that it was contagious, but 
passed resolutions in favor of compulsory notification and iso- 
lation wherever practicable. Non-contagionists still exist, how- 
ever, among many whose long practical experience in leprosy 
countries or their careful study of the question entitles their 
opinions to consideration. 

The circumstances that maculo-anesthetic lepra is the preva- 
lent form in India, and that it is most likely, mainly through 
pus inoculation, or by inhaling bacilli given off from leprous 
air passages, that the disease is propagated from one individual 
to another, and therefore chiefly through the nodular form, are 
probably reasons which have led many authorities in India (to 

* Brit. Med. Jour., June 26, 1886, May 24, 1888, and April 19, 1890, pp. 
909 and 917. See also November 12, 1887, an article on the "Spread of 
Leprosy by Contagion," with many cases, and also Besnier's pamphlet, 
published by Masson (Paris, 1887); also a paper by Poupinel de Valence, 
" Is Leprosy Contagious?" Lancet, May 17, 1890. 

58 



914 



DISEASES OF THE SKIN. 



which Vandyke Carter is a notable exception) to deny the com- 
municability of the disease, while most West Indian authori- 
ties, with the exception of the late Beaven Rake, are in favor 
of its inoculability. 

The invariable presence of bacilli in the tissues, and the fact 
that the prevalence of leprosy in Norway has been diminished 
fifty per cent, in twenty years * by segregation, afford a pre- 
sumption in favor of the contagious theory corroborated by 
its spread in previously virgin countries, e. g., Hawaii, British 
Guiana, etc. 

The failure to inoculate animals is not of much weight, as the 
many failures to inoculate syphilis in animals testify. More- 
over Vrondriansky states that if the animals are subjected to 
starvation, cold, etc., they may be successfully inoculated with 
leprosy. This requires confirmation. 

The evidence grows very strong that under favorable circum- 
stances it may be inoculable in man even by vaccination, f while 
coitus,! prolonged contact, and even breathing in the same at- 
mosphere for a long period, seem to have produced it in some 
instances. 

Arning inoculated a criminal apparently successfully. Subse- 
quently doubt was thrown upon it because it was shown that 
several members of his family were leprous. Hatch of Bom- 
bay reports a case of a student who cut himself while making 
a post-mortem on a leper; this was followed by symptoms of 
leprosy, the ulnar nerve being specially affected. Vandyke 
Carter also saw the case, and concurred in the diagnosis of 
leprosy; but the patient recovered apparently in about a year. 
Several attempts at inoculation by the skin have failed, and,, 
as in so many admittedly contagious diseases, some other fac- 
tors besides the introduction of the microbe to the man are 

* Hansen says dropped from 2833 in 1856 to 321 in the asylums in 1895. 
Isolation is partially compulsory only since 1885. In June, 1902, he 
reckoned the number of lepers in the whole of Norway as about 400. 
Many dispute the efficacy of segregation. 

f Also Daubler's case. See under Vaccination, Rashes, p. 475. An 
interesting case is reported by Gairdner in Brit. Med. Jour., June ir, 
1887. See also correspondence, August 20, September 5, November 5, 
etc., by Beaven Rake, Jelly, and Hillis. Arning found bacilli in the 
vaccine pustule of a leper's arm. 

\ Nevertheless it is rarely transmitted from husband to wife or vice 
versa. 



LEPRA. 



9i5 



required. All agree that the maculo-anesthetic form is less 
easily communicable than the tuberculated form. According to 
Morrow, Jeanselme, Sticker, etc., the entrance of bacilli by the 
nasal passage is far more frequent than by the skin, an idea 
that dates back to Pliny. Sticker examined 400 lepers, 153 
bacteriologically, and stated that he had discovered the primary 
lesion in the shape of an ulcer, rarely a nodule, on the nasal 
mucous membrane, usually on the cartilaginous part. Out of 
the 153 cases it was absent only 13 times, and bacilli were pres- 
ent in 128 cases. No doubt ulcers of the nose are very common 
in lepers, but unless they precede other manifestations their 
presence would be no proof that they were the initial lesions, 
and there are other acid-fast bacilli besides those of leprosy 
and tubercle. Babes goes so far as to say that the nares are 
more likely outlets than inlets. Schaffer says that lepers when 
talking loudly throw out thousands of bacilli by the nasal and 
buccal mucous membranes. In an advanced leper in U. C. H., 
after prolonged blowing on a moistened glass, not a single 
bacillus could be found. Doubtless there are many methods by 
which the bacilli may be introduced, e. g., by contaminated 
food, soil, dirty linen, etc. The mosquito as a possible bacillus 
carrier must also be borne in mind. 

One difficulty in proving contagion is that the incubation, or 
at all events the latent period, is often very long, the disease 
sometimes not declaring itself for years * after exposure to the 
leprous influence, it being generally lighted up by some febrile 
disturbance or depressing influence. This is necessarily a great 
obstacle to tracing the real source of the disease in any par- 
ticular case. Communicability otherwise than by inoculation 
is doubtless rare under ordinary conditions, and it is probable 
that it is so only in the same way that phthisis may be com- 
municated by prolonged association in a confined space and 
breathing a highly contaminated atmosphere. The bad hygienic 
conditions in which lepers often live in most countries in which 
leprosy is rife are highly conducive to the spread of the most 
feebly contagious disease. On the other hand, improved hygiene 
has in many countries not only stamped out the disease, but 

* The longest interval I have met with is eleven years, but Hallopeau 
relates the case of a man in whom the symptoms first appeared thirty-two 
years after a fifteen months' residence in Martinique. 



9 i6 DISEASES OF THE SKIN. 

prevented its propagation, even when, as in England, many 
lepers are yearly introduced from without, whatever may be the 
mode of infection. One fact stands out clearly, that intimate 
association with lepers is fraught with danger. Even in India 
the non-contagionist commission showed that five per cent, of 
those who live intimately with lepers contract the disease, and 
it is calculated that if this proportion were true for the general 
population, there would be ten million lepers in India. Lohke 
of Oesel relates that a leprous woman came into a leprous free 
district and lived in a house with seven other sound men and 
women, all developed leprosy; and many similar though less 
strong instances could be adduced. 

Pathology. — No one now disputes that the disease is due to 
special bacilli which lead to the formation of granulation tissue 
either nodular or infiltrating, and a low form of inflammation, 
and that for a long time the lesions are either in the skin or 
peripheral nerves or both, while visceral infection is a late 
phenomenon. In its general behavior it resembles in some 
ways syphilis, and in others tuberculosis. It has, however, its 
own peculiarities, and the most striking of these is its extreme 
slowness in evolution and course. 

Anatomy.* — The pathology and anatomy of leprosy has been investi- 
gated by a host of observers, but the important discovery of the 
pathogenic bacillus was made by Hansen of Bergen in 1873 in unstained 
preparations, and soon after both he and Neisser succeeded in staining 
it. Both in staining reactions, appearance, and dimensions it closely 
resembles the tubercle bacillus, but is somewhat shorter and takes the 
stain rather more readily, and both bacilli are acid-fast, i. e., not easily 
decolorized by mineral acid solutions; the substance which takes the 
stain in the case of the tubercle bacillus, and probably, therefore, in the 
lepra bacillus, being, as Bulloch and Macleod have shown, a sort of wax. 
The bacilli are variable: they may be straight, slightly curved, tapering 
at both ends or at one end only, the other being knoblike, or both ends 
may be thickened. Cornil states that they are larger in parenchymatous 
organs, such as the liver and testicle, than in the skin nodules. A row of 
minute clear rounded spaces may sometimes be seen, but whether spores 
or part of an involution process is a matter of dispute. 

Unlike human tubercle bacilli, those of lepra are found in sections of 
the nodules in huge quantities, chiefly aggregated in groups, bundles, and 
colonies, but similar features have been observed in avian tuberculosis. 

*Leloir, " Traite pratique et Theorique del a Lepre," 1886; Unna's 
" Histopathology," 1896, p. 616; Trans. Lepra Conference at Berlin, 1897; 
Babes, " Die Lepra," 1901. 



LEPRA. 



917 



So far lepra bacilli have neither been successfully cultivated outside the 
body* nor inoculated into animals, and even direct attempts to inoculate 
man — e. g., Danielssen's experiments on himself — have failed. Those of 
Arning have already been discussed. 

There has been much dispute as to the position of the bacilli, but it is 
now admitted that they may be either intra- or extra-cellular, but mainly 
extra-cellular. Unna states that the " globi " are not cells, but gleal 
masses, which Pernet suggests are a resting-stage of the parasite. The 
bacilli have been found in all the viscera of the body, as well as in the 
nerves and nerve centers, the bones and bone marrow, but they are 
especially plentiful in the skin nodules and mucous membranes and their 
ulcers, the spleen, liver, and testicles, while in the lungs both tubercle 
and lepra bacilli are often found together, lepers being frequent victims 
to phthisis. 

They are said not to be found in bullae or blister contents, except when 
they are over nodules or infiltrated skin, but they have been found in 
vaccination vesicles of nodular lepers by Auche and Carriere, Arning and 
Simpson. While bacilli may perish in the tissues in the course of time, 
and apparent cures result, Hansen does not believe in their stability, and 
thinks there always remain some foci of latent bacilli, which are liable to 
become active under circumstances favorable for their development. 

Histologically, a leprous nodule is an infective granuloma produced by 
the bacillus either in the derm or hypoderm, separated by a narrow zone 
from the epidermis. The bacilli are abundant in the fat, but not in the 
sebaceous glands; but while they may be found in the hair follicles, it is 
disputed as to whether they are in the sweat coils. In addition to the 
bacilli the nodule is composed of lymphocytes, plasma and mast-cells, 
large flat giant cells, vacuolated cells, and the cells of Langhans, but 
Hansen and Looft think that the last were really in tuberculous, not 
leprous, growths. 

The bacilli infect the vessels, especially the endothelia, so that even 
thrombosis may be produced. The sweat coils are sometimes infiltrated 
with cells, in other cases destroyed. The epidermis is unaffected. The 
granulomatous structure may be in the form of infiltration instead of 
nodule, but histologically the neoplasm is the same, commencing round the 
vessels and glandular structures. The macular eruption of nerve leprosy, 
Neuroleprides of Unna, are not the same as the above. Some observers 
say there are no bacilli in them, others admit that there are a few, but in 
a case of Abraham's with rings, Pernet f found abundance of bacilli. At 
all events they are only indirectly through the nerve lesions the product 
of leprosy, and they may arrest the bacilli in the blood stream, but these 
tend to disappear in the older macules; according to Unna, there are 
older forms of embolic neuro-leprides, which show a transition to sub- 
cutaneous and cutaneous nodules. 

The mucous membranes are affected in the same way as the skin, and 

* The claims of Campana and other workers that they have cultivated 
the bacillus are not accepted. 

f Brit. Jour. Derm., vol. xii. (1900), p. 450. 



9 i8 DISEASES OF THE SKIN. 

bacilli are present in large numbers, the tongue, epiglottis, larynx, and 
nares being most affected. 

In the enlarged nerves, especially the ulnar and peroneal, bacilli are 
abundant, and can best be found in longitudinal sections. The changes 
are both parenchymatous and interstitial, but it is disputed as to whether 
the bacilli are intra- or extra-cellular ; probably they are both. 

The viscera most affected are the liver and spleen, which are enlarged 
and contain vast numbers of bacilli. Amyloid changes are often present 
in these organs and in the kidneys, and large white and granular kidneys 
are common, but nodules are rare, though bacilli may be found. When 
the lungs are affected by leprosy alone a slow sclerosis is said to occur and 
no caseation; but tubercle bacilli are often conjoined toward the end, and 
then caseation and other tuberculous changes occur. 

There are no distinctive changes in the nervous system, but degeneration 
of the cutaneous filaments of the peripheral nerves is common. 

The eye changes are all due to the bacilli, which have been found in 
numerous colonies when they were absent in other parts of the body (Lie). 

Diagnosis. — No mistake in any of the forms can well arise 
when the disease is fully developed. The early symptoms of the 
nodular forms may be mistaken for acute rheumatism, for beri- 
beri, and for ague, and when the patient is in a malarial dis- 
trict the diagnosis may be very difficult, but if he is in a 
leprous district, the extreme drowsiness, the vertigo along with 
epistaxis, should lead to a suspicion of the state of things, espe- 
cially if he has associated with other lepers. 

Difficulties arise from the disease developing sometimes in- 
sidiously, without any prodromal symptoms, the skin manifes- 
tations being the first signs. These, moreover, may be very 
limited in extent, slow in evolution, perhaps a single nodule 
or patch of infiltration, without any apparent cause remaining 
with very little change for weeks or months, and there may or 
may not be loss of sensibility, although in the majority there 
is some sensory disturbance which may need careful investiga- 
tion for its detection. In doubtful cases the bacilli should be 
looked for, though it must be admitted that in some cases 
indisputable on clinical grounds, very good observers have 
sometimes failed to find the bacillus, but the mode of investiga- 
tion is of the highest importance. 

The early eruption of leprosy may resemble some cases of 
erythema exiidatizmm, but the absence of hyperesthesia or anes- 
thesia in the latter, and the febrile symptoms being only slight 
or absent, are distinguishing features. Moreover, erythema 



LEPRA. gig 

papules are, as a rule, not so large, and when they spread, clear 
up in the center; on the other hand, leprous erythema may 
form in rings from the first, but they do not spread at the 
margin and involute in the center, but remain unchanged for 
some days or weeks; the ring is broad in comparison to the 
clear center, the color is a deep crimson-lake hue. 

They are less often seen on the face than lepra spots, and 
the whole disease runs a more acute course, leaving at the most 
transitory, bruise-like stains, while the eruption of lepra is very 
persistent, fading to orange-colored spots, remaining slightly 
elevated and lasting for months. 

In syphilitic roseola the patches are small, not over three- 
quarters of an inch in diameter, very little raised, and the other 
symptoms of syphilis would certainly be present. 

The nodules may resemble those of syphilis, and on the whole 
that is the disease for which leprosy is most likely to be mis- 
taken before the symptoms are fully developed. 

Leprous nodules have their special seat of predilection; those 
of syphilis are indiscriminate, and may come where leprous 
nodules never, or rarely, appear. Moreover, the nodules of 
syphilis are not grouped, have a characteristically depressed 
center after a time, and run a more acute course, whether they 
become absorbed or break down. I have twice seen leprosy 
and syphilis combined; the presence of anesthesia helped to 
distinguish in one case, while in the other the facial aspect of 
lepra was characteristic. Some sensory disturbance is usually 
present. 

From lupus vulgaris nodules, those of leprosy are distin- 
guished by being symmetrically disposed to some extent and by 
their being more persistent. 

In mixed lepra, if ulceration of the palate and destruction of 
nasal cartilages were present, syphilis would be suggested; but 
by this time anesthesia would have set in, which would practi- 
cally exclude syphilis, and then further investigation would re- 
veal that the patient had other symptoms of leprosy. 

The maculo-anesthetic form has been mistaken for syrin- 
gomyelia; but though the sensory symptoms of the presence of 
tactile sensibility and the absence of sensibility to pain, heat, 
and cold were similar, the patient had paralysis of the orbicularis 
palpebrarum, thickening of the ulnar nerves, and had lived in 



9 2o DISEASES OF THE SKIN. 

Tonkin. Characteristic skin lesions, too, are rarely absent. 
Great care is required, in rare instances, when the nerve symp- 
toms are unilateral. See also Morvan's Disease. 

Although the symptoms of syringomyelia and its variant, 
Morvan's disease, may be observed in a few cases of leprosy, 
Zambaco's views that they are merely atavistic forms of leprosy 
justly meet with scant acceptance, and are further discounted 
from his saying the same of ainhum, diffuse and circumscribed 
sclerodermia, progressive muscular atrophy, and Raynaud's 
disease. 

Prognosis. — The disease is almost invariably fatal, and even 
though existence is prolonged for many years, it is at best a 
miserable one. 

Recovery occasionally takes place in temperate climates, both 
in the nodular and maculo-anesthetic form; but the chance is 
better for the nerve form, though there is more or less perma- 
nent disablement. 

The duration varies greatly, according to the form of the 
leprosy; the nodular is soonest fatal, the mixed next, and the 
maculo-anesthetic least. The average duration of the first is 
eight years, of the second ten years, and of the third fifteen. 
Mental depression, and the patient being young, are unfavorable 
circumstances in all forms. 

A well-developed case of nodular leprosy of three years* 
standing left the West Indies and came under my care in 1888. 
He improved considerably up to 1897, when he began to have 
irido-cyclitis; this led to blindness in two years. In 1898 
nodulation and infiltration of the face, which had cleared up, 
began to recur, and at the end of 1899 was very marked; even 
then he said in his general health he never felt better in his 
life, and it had not failed in August, 1902. For the first five 
years from 1888 he had no febrile exacerbations, the first one 
being determined by a tuberculin injection of minimal quantity. 

In nodular lepra unfavorable symptoms are the febrile 
exacerbations being frequent, the air passages being involved, 
and the internal organs extensively implicated, in which case 
the febrile symptoms are more severe and the urea excretion 
greater, while extensive ulceration and the supervention of 
lardaceous disease are signs of especially bad import. 

Favorable elements are: the patient coming under treatment 



LEPRA. 921 

early, removal to a temperate climate, the absence of serious 
complications, the nodules shrinking, and the febrile exacerba- 
tions occurring at long intervals. Diffuse infiltration is better 
than many nodules, the progress being slower, the fever lower, 
and the case more amenable to treatment. In maculo-anesthetic 
lepra, the disease is almost as certainly fatal in the long run, but 
the end is much further off, and if seen early, or the nerve im- 
plication is not extensive, and there are no serious complica- 
tions, the disease * may be arrested, and even improvement in 
the sensory symptoms, with return of sweat secretion, be ob- 
tained; eventually, however, the eruption spreads, the bones dis- 
integrate and lead to mutilations with all the other troubles 
already described. 

In the mixed form the patient is liable to the accidents of both 
forms, but, on the whole, the disease is rather slower than the 
purely nodular cases in its progress, but ulceration of the soft 
palate is especially liable to occur in this form, and add to the 
other troubles. 

Treatment. — This, unfortunately, has hitherto only been pal- 
liative or preventive, the number of so-called specifics bearing 
testimony to the incurability of the disease. Evidence is, how- 
ever, accumulating that we may hope for better results in the 
future, and even now in temperate climates the duration of the 
disease may be considerably extended beyond previous 
averages. 

Most authorities recommend a change to a temperate climate, 
and certainly patients should be removed from districts where 
the disease is endemic. There can be but little doubt, however, 
that cold and variable climates have an unfavorable influence, by 
increasing the liability to chills. 

When the febrile exacerbation is present, full doses of quinine 
should be given, five grains of the sulphate or hydrochlorate 
every four hours combined with an effervescing potash mixture. 
The strength should be carefully supported by highly nourishing 
diet, and hot baths are especially useful. Iodid of potassium 
is contra-indicated at this stage; according to Wolff, it makes 

*Mr. Hutchinson showed a case at the International Congress of 1881 
of a woman who had had this form of leprosy thirty years before, and 
was quite well except that she had still paralysis of the arms and anes- 
thesia. He says that many of these cured cases end in tuberculosis. 



9 22 DISEASES OF THE SKIN. 

the fever violent, the nodules ulcerate, and fresh nodules appear 
with presence of bacilli in the blood. In one case within my 
knowledge it produced purpura. Cod-liver oil, after the febrile 
symptoms have subsided, is beneficial. It is an exploded error 
that there is any disadvantage in healing the sores as soon as 
possible, and they should be treated on general antiseptic prin- 
ciples; iodoform and wet boracic acid lint, e. g., are good appli- 
cations, but when very extensive, finely carded oakum over 
a simple dressing is cheap and efficient, and prevents the fetor 
which too often poisons the air of asylums (Hillis). 

Arning recommended salicylate of soda, from seven to fifteen 
grains three times a day. I have given it in two cases during 
periods of inactivity, but was unable to observe benefit from it, 
but it may be more useful in the more active disease of tropical 
climates or in the febrile exacerbation stage; and, indeed, 
Barnes, of the British Guiana Leper Asylum, says it acts like 
a charm in leprotic fever. Its analogue, salicin, might be sub- 
stituted at this stage, as it can be taken in twenty- or thirty- 
grain doses or more, and seldom upsets the patient. Leitz has 
also recommended the administration of salol. 

Of the many older so-called specifics recommended, only 
two * have to some extent stood the test of long experience — 
Chaulmoogra oil and Gurjun oil from dipterocarpus laevis. 
These oils are taken internally and rubbed in externally; both 
are very nauseous, and are best given in emulsion or capsules, 
beginning with small doses. The Chaulmoogra oil should be 
begun in doses of three minims, or one capsule, three times a 
day after meals, and gradually increased up to the limits of 
the patient's endurance, experience having shown that the re- 
sult is far more satisfactory when large quantities, such as one 
hundred drops or more a day, can be taken, but it is seldom 
that more than a dram a clay, and often less, can be tolerated, 
nausea, vomiting, and diarrhea ensuing, if the limit of the indi- 
vidual is exceeded. According to Oro Mario, the number of 
bacilli diminish under its use. Gynocardic acid has been 

* " Kauti " was a celebrated secret cure by a Hindoo named Bhau Daji. 
It is an oil derived from a plant which he pointed out to a relative of 
Mr. Stanley Boyd, who informs me that its name is known as t^dno- 
carpus imbricans. It somewhat resembles Chaulmoogra oil, which 
Desprez and Prain state is also from a hydnocarpus. 



LEPRA. 923 

recommended in doses beginning at half a grain, and gradually 
increasing it up to forty-five grains three times a day. The 
oil also should be well rubbed in, in the form of an ointment, 
consisting of equal parts of the oil and lard; the friction should 
be thorough and prolonged, where possible for two hours a 
day, previously cleaning off the old oil with fuller's earth, or 
by the aid of a warm bath. I have seen one case of the mixed 
form in a man, set. thirty-five, in which a perfect cure resulted 
apparently from taking Chaulmoogra oil in enormous doses. 
The disease was contracted in Paraguay, had existed five years, 
and was at its worst one and a half years previously. He began 
with small doses of Chaulmoogra oil, but could not tolerate 
much until he went up into the mountains. There he reached 
two hundred minims of oil per diem, and immediately began to 
improve; ultimately he reached five hundred in a day, and all 
symptoms absolutely disappeared except small areas of anes- 
thesia on the upper and lower limbs. 

Tourtoulis Bey * injected Chaulmoogra oil subcutaneously, 
five grams a day. There was marked improvement after fifty- 
injections. Subsequently the patient underwent 584 injections, 
spread over six years, and was considered to be cured. On 
the other hand, Miquel says that the injections are painful and 
sometimes provoke local reaction, and Du Castel and Hal- 
lopeau say it may produce fat embolisms, so it must not be 
used indiscriminately, but all agree that the leprous manifesta- 
tions improve under it. 

Strychnia or nux vomica may be advantageously combined 
with Chaulmoogra, and assists in enabling the patient to tolerate 
it. Piffard and others have a high opinion of strychnia by itself 
as a remedy. When Gurjun oil is employed — and it is spoken 
of most highly by those who have used it in the tropics — it is 
given internally, in an emulsion consisting of lime-water three 
parts and Gurjun oil one part, half an ounce being given twice 
a day; at the same time, a liniment of equal parts of the oil 
and lime-water is rubbed in, in the same way as the Chaul- 
moogra. I have found that, in this climate, the emulsion cannot 
be made by this formula, the oil being too solid. For the mix- 
ture it was found best to rub it up with powdered gum arabic 
and water; but English patients could not take more than a dram 
*Abs. Brit. Med. Jour. Supp., November 11, 1899. 



924 DISEASES OF THE SKIN. 

a day, and that only by raising it very gradually from a five- 
minim dose. The liniment can be made with olive oil instead 
of lime-water. In the writer's hands the Chaulmoogra oil ap- 
peared to be more useful than Gurjun, but in the tropics Gurjun 
is more valued. I have found simple oils quite as useful for 
a liniment, and greasy applications always seem grateful to the 
leper. Besides direct medication, frequent baths, especially 
Turkish, are to be used, and strict attention to general hygiene 
should be paid. A very liberal dietary should be ordered, and 
Hutchinson advises a good allowance of a generous wine. 
Sulphur baths are strongly recommended by some, and since 
scabies is a very common complication in the tropics, sulphur has 
a double advantage. The patient should be well and suitably 
clad according to the climate, and chills carefully avoided, as 
they frequently seem to determine a fresh exacerbation. 
Other remedies have had advocates lately. Unna claims to 
have cured a case with sulpho-ichthyolate of soda or am- 
monium, combined with the use of external reducing agents. 
The soda salt has entirely failed in my hands in two cases. 
In a boy of ten, in an early stage, five-grain doses produced 
anorexia, nausea, and vomiting, and an older nodulated case 
could not get beyond eight grains three times a day. There 
was no improvement in the leprous symptoms. 

Tuberculin excited great hopes for a time, on account of the 
marked reactions produced by it in lepers; subsequent experi- 
ence has shown that it is not only not of permanent benefit, but 
that it is dangerous,* as it sets free the bacilli instead of de- 
stroying them. In a nodulated case under me, which had been 
free from febrile attacks for three years, two milligrams ex- 
cited an attack of leprous fever of a remittent type which lasted 
three weeks, and a copious outbreak of fresh nodules ensued. 
They disappeared again with frictions of Gurjun oil liniment, 
and ultimately he was no worse, perhaps had a little less infiltra- 
tion, but it was too dangerous an experiment to repeat. 

Coley's Fluid (the toxins of erysipelas and bacillus prodigi- 
osus) has also been given by injection with no good effect. 

Carrasquilla of Bogota claimed to have had good results by 
injecting serum from a horse into which serum from leprous 

* See a summary of the effects of tuberculin in leprosy in a leader in 
the Lancet, April 16, 1892. 



LEPRA. 925 

blood had been injected. The results have been disappointing 
in the hands of others, there having been only transitory im- 
provement, and even this has been ascribed to the reaction 
which can be obtained from products obtainable from normal 
serum. This, Kermogant points out, produces temporary in- 
volution of some malignant growths. There is no doubt, how- 
ever, that in some cases diminution of the infiltration has 
occurred from the so-called leprous serum — e. g., Buzzi's case — 
but it has not lasted and the injections are not free from danger. 

Mercurial Injections. In the Lancet of August 8, 1896, I 
published the results of intramuscular injections of perchlorid 
of mercury,* one-quarter of a grain in twenty minims being 
injected into the buttock once or twice a week. The effect was 
most striking in removing the infiltration and improving the 
general state of the patient in the case related. The injections 
were continued for over two years once a week without any 
salivation or ill-effects, and three years after the commence- 
ment of the treatment the improvement was maintained. Other 
cases similarly treated have improved almost as much, but in 
some of them there has been a recurrence of nodules some 
months after discontinuing the treatment. The perchlorid gives 
pain at the time of injection and leaves an induration, at first 
tender, for some time afterwards; latterly, therefore, I have 
used the sozoiodolate of mercury in the same dose, dissolved 
by adding an equal weight of iodid of sodium. This solution is 
not nearly so painful either at the time or afterwards. It is 
important to plunge the needle well into the buttock, as sub- 
cutaneous injections are much more painful and liable to pro- 
duce sloughing. At first I was in hopes that the mercury acted 
by destroying the bacilli, but the recurrence of nodules in quite 
new situations suggests that the infiltration is merely absorbed, 
and that some at least of the bacilli get free. It ought to be 
possible to attack some of these free bacilli either by salicin, 
which breaks up into salicylic and carbolic acids in the blood, 
or by the simultaneous administration of Chaulmoogra oil. 
Latterly, also, I have thought there was some advantage in 
carrying on the injections for three months, then waiting three 

* Haslund of Copenhagen has also used independently these injections 
with benefit. 



926 DISEASES OF THE SKIN* 

months and resuming injections. As in syphilis, it may take 
a long time to discover the best method of getting permanent 
results by these injections, and in that disease also cure cannot 
be promised by specifics, though their good effect is undeniable. 
Administration of mercury by the mouth does not produce 
equivalent effects; at all events, no other known treatment pro- 
duces such rapid improvement in the appearance and general 
well-being of the patient, and it does not interfere with any 
other measures deemed advisable for his welfare. As might 
be anticipated, the results are not so striking in the nerve 
form, though improvement does result if the cases are of not 
too long standing. The leprotic eye affections have not been 
influenced by it in three cases in which I have tried it, even 
while other lesions were improved. Since the above was 
written I have had two cases in which the disease is apparently 
kept in abeyance by intermittent injections; and the treatment 
has been found advantageous by other observers, especially 
Neish of Jamaica and Lie, while others have failed to get any 
good results. 

Locally. — Friction with Chaulmoogra, Gurjun, or even olive 
oil, is always a useful measure, and appears to facilitate the 
absorption of nodules. Unna claims to get good results by 
inunction of chrysarobin and ichthyol eight parts, salicylic acid 
two parts, vaselin one hundred parts, using pyrogallic acid in- 
stead of chrysarobin on the face. With this and ichthyol in- 
ternally he claimed to have cured a case, but the patient died 
in a miserable condition a year later in Brazil. The fact is, 
friction with any greasy substance may produce temporary im- 
provement. De Brun of Beyrout produced marked improve- 
ment with ichthyol internally for some months, the quantity 
reached ten grams a day. In the anesthetic form nerve-stretch- 
ing and nerve-splitting have been found useful in restoring 
sensibility, muscular power, and healing ulcers, and some 
permanent improvement, also relief from the shooting pains so 
common in this form. Antipyrin gr. v. and phenacetin inter- 
nally are worth trying for the shooting pains. Perforating 
ulcers from lepra can be treated as successfully as from other 
causes. (Vide separate article, p. 705.) 

As preventive measures, segregation is the only effective plan, 
and it is probable that the disease was stamped out of England 



RHINOSCLEROMA. 92 7 

and the greater part of Europe by this means, and great 
diminution in the number of lepers has ensued in Norway since 
its adoption. Kanthack, Collins, etc., dispute this, and ascribe 
it to improved hygiene generally asserting that diminution of 
leprosy in Norway began before measures of segregation were 
adopted, and that segregation was not strictly carried out in 
that country. The undoubted fact that people who have pro- 
longed intimacy with lepers are exceedingly likely to contract 
the disease is much in favor of segregation, and the balance of 
evidence and opinion of the highest authorities is in favor of it. 
Hansen, who has had the best opportunities for investigating 
the subject, is a convinced contagionist and advocate for segre- 
gation. Those who have to dress the sores of lepers should be 
very careful if they have scratches or abrasions, and not neglect 
carbolic acid or corrosive sublimate ablutions afterwards. 

RHINOSCLEROMA.* 

Definition. — A granulation new growth of almost stony hard- 
ness, affecting the anterior nares and adjacent parts. 

This disease was first described by Hebra and Kaposi in 1870 
from seven cases, and their account was extended by the ex- 
perience of other cases in their classical work, from which the 
following account is taken, there having been only three in- 
stances f in England out of about two hundred known cases. 

* Literature. — Hebra's " Skin Diseases," vol. iv. p. 1. Monograph by 
Celso Pellizzari (Florence, 1883). Good analysis in Ann. de Derm, et de 
Syph., vol. iv. (1883), p. 549; in volume for 1890, p. 173, is a full analysis 
of a good paper by Wolkowitsch. A paper by A. Castex, in Jour. Malad. 
Cutandes, vol. iv. (1892), p. 161, gives a resume and bibliography to date. 
Ducrey, 1893, has complete illustrated monograph on four Italian cases. 
Abs. in Annates de Derm., vol. v. (1894) p. 131. Kaposi's Hand Atlas, 
Plates CCLXXXIX. and CCXC, et seq. 

f Semon's and Payne's case, a South American Spaniard, Path. 
Trans., vol. xxxvi., 1835, colored plates and histology. This is the 
same case which had been in Paris, and was histologically examined by 
Cornil, Prog. Med., torn. xi. (1883), p. 587. I saw this case both at St. 
Thomas' Hospital and at the Pathological Society. He was a native of 
Gautemala, set. eighteen, and the disease had been present four years. 
Morell Mackenzie, in Brit. Med. Jour, for March 21, 1885. gave a further 
account of this case, and in his work on "Diseases of the Throat and 
Nose " he gives a summary from forty cases. W. Anderson showed a 



928 DISEASES OF THE SKIN. 

(Up to 1895 Kaposi had seen fifty cases.) The disease occurs 
chiefly in the Austrian Empire and Southwest Russia. A few 
other cases have been observed in Italy, Spain, Switzerland, 
Belgium, and Sweden, at San Salvador, and other parts of 
Central America, in Brazil, where it is said to be not very rare, 
and a case from Egypt has been reported by S. Davies. Vidal 
had a case from Buenos Ayres, and Besnier's and the other 
Parisian cases were also foreigners. Kiegan relates four cases 
in Hindoos in the Indore Hospital. Indigenous North Amer- 
ican cases have been reported by Bulkley, Jackson, Klotz, 
Wende,* etc. 

Symptoms. — The disease generally commences in the mucous 
membrane of the anterior nares and the adjoining skin. Wol- 
kowitsch analyzed 85 cases, and found the regions attacked 
were: Nasal fossae, 81; exterior of nose, 74; pharynx, 57; upper 
lip, 46; larynx, 19; palatine arch and velum, 17; upper alveolar 
border, 16; trachea, 5; lacrymal sac, 5; tongue, 4; lower lip, 2; 
ear, 1. Pick and Kaposi have also observed it in the auditory 
canals. 

The lesions consist of flattish, isolated, or coalescent nodules 
or raised plaques, imbedded in the cutis vera, or deeper layers 
of the mucous membrane, and sharply defined from the normal 
skin. The growth is peculiarly hard to the touch, though not 
entirely devoid of elasticity, smooth, glossy, and either of 
normal color veined with dilated vessels, or of a uniformly 
bright or dark brownish-red color, quite devoid of hair or 
glands. The epidermis covering it is tense and easily cracked, 
forming rhagades at the natural folds, and from these exude 
a viscid secretion, which dries into yellowish adherent scabs. 
It is not spontaneously painful, but aches severely after firm 
pressure. 

It commences quite painlessly, as a simple induration, on the 
inside of the alae nasi, the mucous membrane of the septum or 
from the upper lip, grows slowly, but with a tendency to spread, 

case of a boy, set. thirteen, at the Dermatological Society in 1890. It had 
recurred five years after removal. The boy was born in England, but 
looked as if he were of foreign extraction. 

* Jackson, Amer. Jour. Cut. D/s., vol. xi. (1893), p. 381, with good 
colored plate. Wende, loc. cit., vol. xiv. (1896), p. 90, was a native-born 
American boy. Jackson's was a Hungarian woman. Klotz's a German 
woman who always responded to specific treatment. 



RHINOSCLEROMA . 929 

but never to spontaneous involution, and it may last for years 
without any change except superficial excoriation. At a late 
stage a viscid exudation occurs, and dries into a yellow crust. 
If any attempt at removal is made, it recurs comparatively 
rapidly, but is always a purely local disease, not affecting the 
health in any way except from its mechanical obstruction of the 
nostrils, which may be quite occluded when it is fully developed, 
and dangerous symptoms may arise from obstruction of the 
pharynx or larynx. At the same time it widens and flattens the 
nose, making the front part very tense and hard, while it may 
gradually implicate the whole thickness of the upper lip; and in 
Salzer's case spread even to the periosteum and bone itself of 
the superior maxilla. 

Variations. — In one case it began on the velum and hard 
palate, in another as a hard polypoid tumor from the mucous 
membrane of the nose. There is also, often, absorption of the 
septum nasi from pressure, once perforation of the hard palate, 
but not from tumor, and once perforation of the skull into the 
brain (Kaposi) ; there has also been cicatricial-like sclerosis, but 
with very little tendency to tumor formation, in the pharynx, 
palate, and other parts. It is said never to break down except 
from injudicious treatment, but Zeissl's * case did; superficial 
ulceration when it is in mucous membranes may occur. Inter- 
current erysipelas and threatened suffocation are the chief dan- 
gers, otherwise the disease may go on for fifteen or twenty 
years, and a case lasting twenty-seven years is on record. 
Lubliner records a case of spontaneous disapparance after 
typhus, and Lutz a doubtful one after typhoid. Klotz's case was 
improved for some months by scarlatina. 

Etiology. — Both sexes are almost equally liable, and the ages 
hitherto have been from nine to forty. In Robertson's cases 
two sisters were attacked. The subjects are from the very poor, 
but are in good health. Beyond this nothing is known as to 
causation, but its narrow geographical limits suggest some kind 
of endemic influence. 

Pathology. — On the whole these investigators regard the infil- 
tration as sui generis, whose nearest relations are with granula- 
tion tumors, such as are seen in lupus, tubercle, syphilis, and 

* Zeissl's "Syphilis," Plate XXIV. Lang had a case which simulated 
an ulcerating carcinoma. 

59 



930 DISEASES OF THE SKIN. 

leprosy. Noyes and Unna are inclined to the view that the 
growth is an inflammatory product consequent on the blocking 
of the lymphatics by the bacilli. 

Anatomy. — The anatomy has been investigated by Kaposi, Mikulicz,. 
Cornil, Payne, Rona, Marschalko, and others, with general agreement. 
The chief change is in the corium, in which the papillae are elongated, 
and there is a dense granulation-like cell infiltration, with, in some parts, 
epithelial cells also, but not true giant cells, though Cornil describes 
large round cells with one or several nuclei; these are the same as 
described by Mibelli, confirmed by Noyes, and are of two kinds — so- 
called hyaline and colloid cells. The latter Noyes traced in various 
stages from infiltration round cells; bacilli in preponderating numbers 
are found in both kinds, but most in the watery cells from which the 
colloid cells are derived. Mibelli, however, ascribes these cells not to 
degeneration of the cell, but that their protoplasm has been replaced 
by the glea of the rhinoscleroma bacillus. Pawlowsky takes the 
same view. There is not much stroma as a rule, but in parts there 
is a very dense fibrous tissue. The epidermis is generally not much 
altered, but Payne and Mikulicz describe considerable branched down- 
growth of the interpapillary processes, and Payne also found in the epi- 
dermis nests very like those of epithelioma, but containing an imprisoned 
hair. Frisch, confirmed by Cornil and Alvarez, Paltauf, Payne, etc., 
found characteristic * bacilli, short, thick, ovoid, and capsulated, and 
staining only at the ends; these occur either in free groups or in cells, in 
places where the epithelioid cells are most abundant. They closely re- 
semble the pneumococci of Friedlander, but are considered to be quite dis- 
tinct by Dittrich, Cornil, Alvarez, Rydygier, Ducrey, Paltauf, etc., while 
others consider them identical. Friedlander's bacillus produces more 
rapid fermentation in a one per cent, solution of grape sugar, will grow in 
an acid medium, and will coagulate milk — all points of difference from 
Frisch's bacilli. 

Some recent observers, such asSecchi and Ducrey, do not consider that 
the bacilli of Frisch are the pathogenetic agents, while Rona and Mar- 
schalko do think so. The latter has made very careful observations, and 
concludes that the hyaline and colloid cells are degenerated plasma cells 
and are not specific to rhinoscleroma, as hitherto supposed, and are met 

* They are best demonstrated by prolonged staining (twenty-four hours 
or more) with five percent, solution of methyl or gentian violet in saturated 
aniline water, and decolorization with Gram's iodin solution. Mibelli 
prefers Grenadier's alum carmine. The sections are placed in a four per 
cent, solution in hot water, and allowed to remain an hour or more — 
twenty-four hours are not injurious. They are then washed in water, 
treated with alcohol in the usual way, and mounted in dammar. The 
bacilli could be easily found in infiltration cells, but only in those which 
had undergone some change. Their size is 2 to 2.5 fi long and .5 p thick, 
usually grouped. 



RH1N0SCLER0MA. 93 r 

with in other processes; but a large proportion of plasma cells are trans- 
formed into rhinoscleroma tissue by regressive degeneration. The only- 
specific elements besides the bacilli are the cells of Mikulicz, which are 
connective tissue cells degenerated by the action of the bacilli, of which 
they contain enormous numbers in glese. The cells increase in size to 
bursting point and then scatter the bacilli through the tissues. The 
cells then perish, and are replaced by the hard collagenous tissue char- 
acteristic of the disease. 

Diagnosis. — The stony hardness, slow painless growth with- 
out disintegration, and its predilection for the anterior nares, 
are pretty characteristic from the dermatologist's point of view, 
and when it commences in the pharynx or larynx the case is 
not likely to come to him. In some of these respects it is imi- 
tated by syphilitic nodules, keloid, and epithelioma. 

Syphilitic infiltration offers trouble only at first, as it soon 
shows signs of disintegration, and any doubt would be resolved 
by the administration of specifics, in most cases, though in 
some, such as one of Hebra's and that of Klotz, temporary im- 
provement occurred under mercury. 

Keloid, with dilated vessels over it, would be very like, but is 
rarely met with about the nose; a history of a previous scar 
would help, but microscopic investigations of an excised por- 
tion might be necessary for certainty. 

Epithelioma is extremely rare on the upper lip, and being on 
the border of the mucous membrane and the skin would ulcerate 
comparatively early; before this the pearly, vesicular-looking 
nodules on the border of an epithelioma would assist to a right 
conclusion. Some sarcomas are very like it at first until they 
begin to break down. 

Treatment. — Permanent removal has never yet been accom- 
plished, the disease speedily recurring after excision, probably 
because it is seldom seen early enough to be able to get beyond 
the disease. It is remarkable that it does not cut nearly so 
hard as it feels to the touch. Attempts to keep the nostrils 
permeable have been made by boring through the growth with 
caustic potash, or removal with the sharp spoon, but only tem- 
porary relief has been afforded, though the perforations may be 
kept open by antiseptic tampons. As the patients live long 
with comparatively little discomfort it is probably better to leave 
them alone, as far as operative interference is concerned, except 
that sounds may have to be used to keep open the air passage 



932 DISEASES OF THE SKIN. 

in the larynx. In one case Lang obtained promising results 
with a salicylic acid treatment, inside and out, as follows : A one 
per cent, solution of salicylic acid was injected into the 
sclerosed parts once a day, later a two per cent, salicylate of soda 
solution was used. Metallic tubes covered with salicylic acid 
plaster were introduced into the nostrils. Naso-pharyngeal 
douches of salicylate of soda were employed, an alcoholic solu- 
tion of the acid applied, where the mucous membranes were 
affected, and salicylic acid snuff ordered; in fact, salicylic ap- 
plications in every conceivable way; and internally, ten grains 
of the salicylate three times a day for two months. One and 
two per cent, solutions of carbolic acid were also used. Very 
great improvement ensued in all parts, the infiltration became 
softer and less conspicuous, and the patient was improving in 
every way, but he had to leave the hospital before he was quite 
cured. This treatment, therefore, deserves further trial. Cor- 
rosive sublimate or thiosinamin injections might be tried. 
Stoukovenkoff had fairly good results by injecting a from one 
to twelve per cent, solution of liquor Fowleri, which arrested 
the progress of the disease, and at the end of fifteen months 
(222 injections) the growth seemed to be disappearing. Arseni- 
cal injections are very painful. Vymola treated a case with 
success at Houl's suggestion, with rhinoscleroma toxin. There 
was a slight rise of temperature; the dose began at ice, and 
was increased to 6c. c. In three months the thickening and 
infiltration had subsided. 



EMBRYOGENIC GROWTHS. 

Synonym. — Nevi. 

Most continental authorities employ the term " nevi " for all 
forms of neoplasm of congenital origin which are present at 
birth, and many use it also for growths which, although due to 
developmental errors, may not have appeared for months or 
years after birth. Custom in England restricts nevi, unless a 
qualifying term is added, to blood-vascular growths. To avoid 
ambiguity, and since in its strict meaning a nevus should be 
present at birth, I here employ the term " embryogenic " for all 



KELOID. 



933 



neoplasms which there are strong grounds for believing derive 
their origin from defects arising in fetal life. 

These are: Some keloid fibroma, neuro-fibroma and neuroma, 
myoma, nsevus pigmentosus, nsevus vascularis, angioma ser- 
piginosum, lymphangiectodes, lymphangioma tuberosum multi- 
plex, epithelioma adenoides cysticum, adenoma sebaceum. 

While the clinical differences of most of these growths gen- 
erally enable them to be readily diagnosed, in some the nature 
of the growth can only be determined with the aid of the 
microscope. 

KELOID. 

Deriv. — XV^V? a claw. 

Synonyms. — Cheloid; Alibert's keloid. 

Definition. — A fibro-cellular, corium new growth, occurring 
after injuries to the cutis, and perhaps spontaneously. 

This disease has no relation to Addison's keloid or morphea. 
The so-called true keloid is a very rare disease, one in two 
thousand according to Hebra and McCall Anderson, though 
some authors give a higher proportion. 

From the time of Alibert, who first clearly described this dis- 
ease, onwards, authors have spoken of a true and false, or 
spontaneous * and scar keloid, f while Dieberg has added the 
hypertrophic scar, Hawkins the verrucose cicatricial tumor, 
and Wilkes the syphilitic keloid. The first tw T o are of the most 
practical importance, and even between these, as will be shown 
in the etiology and pathology, the distinction is probably more 
artificial than real, and is only provisionally retained here, for 
convenience of description. 

Symptoms. — The typical keloid not obviously of scar origin is 
often single, and its most common position is on the trunk, 

* Alibert's Atlas, Plates XXVIII. and XXIX., in the first edition, where 
it is called cancroide. The term cheloid is used for the same lesion, in 
the second edition. 

\ Author's Atlas, Plate LXXII. Hebra, Lief x., Plate V., Figs, i and 2. 
Hutchinson's " Illustration of Clinical Surgery," several plates. Morrow's 
Atlas, Plate LXIII., Fig. 1, in negro. 



934 DISEASES OF THE SKIN. 

especially on the chest over the sternum (half of all cases), 
where it forms a firmly elastic tumor of cicatricial aspect, 
sharply denned, springing up abruptly from the healthy skin, 
and projecting from one-sixteenth to a quarter of an inch or 
more; its shape is very variable, oval or disclike, cylindrical or 
rodlike, and occasionally nodular, often rather narrow in the 
middle in the rod-shaped, and slightly depressed in the center 
in the disc form, which may be pedunculated; and the frequency 
with which it sends out clawlike processes* mainly at each 
end, gained it its appellation. The surface is smooth, the epi- 
dermis tense, unless involution is occurring, and the color is 
white and shining, or pinkish or purplish from dilated vessels 
coursing over it. It is generally tender, and sometimes spon- 
taneously painful, the patient complaining of pricking, burning, 
or itching, which is occasionally severe; on the other hand, 
all these symptoms are often absent, and the claim to distin- 
guish true from false keloid by their presence cannot be main- 
tained. 

After attaining a certain size the tumor may remain sta- 
tionary for an indefinite time, or progress very slowly, e. g., 
Callender's case was observed for ten years, during which 
period it gradually enlarged, while Duckworth's case existed 
forty years, attaining to the size of a horse bean in sixteen 
years, while twenty years later it was two and a quarter by one 
and three-quarter inches. In a case of my own, a gentleman, 
set. sixty-seven, who had numerous large scar keloids on the 
trunk and limbs, they dated from boyhood, fifty-three years 
before, coming on after boils, and some of them had grown 
very large, and were still enlarging. They itched and pricked 
at times, especially after alcohol. (Vide my Atlas). 

Keloids may undergo involution, either partial or complete. 
Three of the tumors in the case just mentioned had disappeared 
completely, leaving the skin which contained them as a loose 
sac, and I have seen three instances of small scar keloids, which 
developed and declined under observation, taking three years 
in a syphilitic keloid in a young man, while in a woman of forty- 
five a keloid following injury had not quite gone in four years. 

* Unna explains that this is due to extension taking place in the course 
of the larger vessels, " Histology," p. 841; and Wilson pointed out that 
they form to join the outlying nodules to the main body. 



KELOID. 



935 



On the other hand, in Goodhart's case, which followed small- 
pox scars, and was well-nigh universal, large tumors involuted 
completely in a few months. Many other cases are on record, 
and Hutchinson thinks that involution is the rule in the keloid 
of young people, while in other subjects its disappearance is 
slow, or does not occur at all. In Erasmus Wilson's case the 
tumor varied in size according to the patient's health. 

Variations. — The less common positions for supposed spon- 
taneous keloid are the face, ears (especially the concha and 
lobule, symmetrical when due to earrings), both surfaces of the 
extremities, the back of the hand and foot, the external geni- 
tals, and in Minges' case it occurred in the urethra. When 
multiple, — and they may be numerous * if they are on the 
chest, — Kaposi says that they are arranged in rows parallel to 
the ribs; but this is certainly not always the case. In de 
Amicis' case, a woman, set. twenty-seven, there were 318, most 
of them spontaneous, and arranged with very exact symmetry. 
They were hemispherical, from a pin's head to a pea in size. 
When small, they may be imbedded in the skin, and only per- 
ceptible to the touch. In Reiss' case, a girl of twelve, there 
were 210, symmetrical on the whole, but not in lines. There 
was no antecedent eruption. The de Amicis, Cazenave, Schwim- 
mer, Kaposi, and Reiss cases form a special group, and are 
perhaps of congenital or nevoid origin, though late in develop- 
ment, and have more claim to be called " spontaneous " than 
any other form. 

Keloids rarely ulcerate or take on a malignant character, but 
a case in which both these complications occurred is recorded 
by W. Anderson. f On the other hand, epithelioma in hyper- 
trophic scar tissue is not so rare, especially if subjected to re- 
peated irritation. (See Epithelioma.) 

*De Amicis' case, " Comptes Rendus," Derm. Cong., Paris, 1889, with 
three colored plates, p. 93; and Vidal, p. 103. In a case of Schwimmer's, p. 
568 of Ziemssen's " Handbook," there were 105. Original communication 
in Viertelj. f. Derm. u. Syph., 1890, p. 225. W. Reiss, Archiv f. Der?n. 
ti. Syph., vol. lvi. (1901), p. 323, with colored plates; very like de Amicis' 
€ase; copious references. 

\ Lancet, May 25, 1888, p. 1025 — the woodcut is in the next number. 
Abraham also records a case of ulceration in a presumed keloid, but 
the diagnosis was open to doubt. Brit. Jour. Derm., vol. x. (1898), 
p. 96. 



93^ 



DISEASES OF THE SKIN. 



Scar Keloids, of course, come anywhere, and, when due to 
the scars of an eruption like acne or smallpox, in any numbers, 
and do not differ in any other particulars, except their origin, 
from the spontaneous form. They spring from the scar, but 
are not always limited to it, often spreading slowly, like the 
others; on the other hand, the hypertrophic scar never spreads 
beyond the limit of the scar, and is simply a thickened cicatrix. 
Keloid is said to be particularly frequent in syphilitic scars, to 
be softer and more likely to involute in them than in others, 
but this is not established as a general rule. Verneuil, how- 
ever, relates that in a case of syphilis, where keloids covered 
the whole body, they all disappeared under iodid of potassium. 
It would be easy, however, to show, from my own and general 
experience, that iodids do not usually make much impression 
on keloids in syphilitics. Bryant says that it is pigmented, 
but this is not especially frequent in my experience, and pig- 
mentation follows the disappearance of non-syphilitic tumors 
sometimes, as in Goodhart's case. 

Keloid en plaque has been described by Hutchinson and R. W- 
Taylor,* in which there is a circumscribed, hard, not well- 
defined plate imbedded deep in the cutis, and projecting very 
slightly or not at all, though it may adhere to the epidermis 
in parts, which is then very pale and smooth, but not glossy. 
In Taylor's case, the result of a bite, the surface was ridged, and 
it could be pinched up. There were also two pedunculated 
fibroma tumors. In one out of the three cases there was pain 
and itching at times. In Hutchinson's two cases there was no 
recurrence after removal. 

In a patient of mine, a surgeon, who had lived in India, there 
was in the interscapular region a large plaque, not raised 
above the surface, the size of the hand, which was first ob- 
served two years before, and had increased in size. There had 
been no antecedent lesion of any kind. In the plaque the 
sebaceous orifices were very obvious, so that the skin looked 
like orange peel, but whiter than the normal skin, and when 
pinched up it was slightly thickened. There was no difference 
in sensibility. The microscope showed fibrous thickening and 

* Taylor, " Molluscum Fibrosum and its Relation to Keloid," Amer. 
Jour. Cut. Dis., vol. v. (1887), p. 168, quotes Hutchinson's cases from 
Med. Times, May 23, 1885. 



KELOID. 937 

condensation in the papillary layer, projecting above the level 
of the skin, while the central portion was depressed below the 
border and was atrophically cicatricial. 

I saw a very peculiar case with Mr. Cursham Corner in a 
woman of sixty-seven. Twenty-eight years before, the disease 
began on the right breast, "like the sting of a wasp"; it was 
not very red, and in five years was only the size of a shilling; 
then another began on the left breast, and both increased to- 
gether, and during the last year more rapidly. When seen each 
lesion formed a ring about five inches in diameter, the border 
varying from one-half to an inch or more. The patches as a 
whole were flat, thin, and indurated, and could be pinched up 
like a plaque in the skin one-eighth of an inch thick, quite 
cutaneous, and not at all adherent to the subjacent tissues. The 
patches itched and burned " dreadfully," and sometimes they 
smarted or she had cutting pains. On the right side there was 
a third oval patch three inches by two and a half, which had 
grown a third larger in eighteen months. It was flatly convex, 
thicker than the others, and nearly uniform, but near the center 
the skin was pale yellow and becoming cicatricial, and there 
were three large comedones upon it. As no histological exami- 
nation could be made the diagnosis is open to dispute, but its 
hardness, slow growth, appearance, and symptoms agreed 
better with keloid than anything else. 

Acne Keloid is a keloid tumor with its long axis transverse, 
which is seen sometimes on the nucha. It has tufts of hair 
imbedded in and projecting from it, as the neoplasm has grown 
up round groups of follicles which have escaped the destructive 
influence of the antecedent process, which is that of a sup- 
purative folliculitis, and has been described by Kaposi under 
the name of dermatitis papillaris capillitii (which see). French 
authors have designated it acne keloid, which well fits the 
terminal part of the process. I saw a well-marked instance in 
a patient of my late colleague, Berkeley Hill, just in time to 
make the diagnosis before it was excised. Microscopical ex- 
amination showed that it was composed of dense fibrous tissue. 

In a patient of mine there was an analogous condition in the 
whiskers, where there was a plaque the size of a shilling formed 
of fibromatous papules with a hair stump in each; the history 



938 DISEASES OF THE SKIN. 

showed that it started from a pus cocci eruption which began 
in the scalp. Balzer and Griffon * report a case of keloidal 
thickening of the scars left by an impetigo on the limbs, in 
which they found streptococci. A similar condition, following 
severe acne on the back, is not uncommon. 

Etiology. — Sex appears to have no influence, though some 
authors state that keloid is more common in women. It may 
occur at any age; one case w r as congenital (Bryant), and it has 
been seen in a child of six months, and at all ages from this 
upwards; but it is rare in old age, and uncommon in puberty. 
It is said to be more common in some races, especially in 
negroes, f in whom it very frequently follows slight injuries, the 
tumors attaining enormous numbers and dimensions. There is 
some evidence $ also of heredity and family predisposition, and 
that there is a strong individual predisposition in some patients 
is obvious. According to Kahler, keloid is one of the charac- 
teristic symptoms of syringomyelia, but this is an exaggeration, 
to say the least. The researches of the Keloid Committee of the 
Clinical Society, § of which I was a member, threw much doubt 
on the spontaneous origin of keloid, and though it could not 
be disproved in the face of such cases as those of de Amicis and 
Vidal, it is certainly much rarer than was formerly supposed. 
This much is, however, certain, that the so-called false or scar 
keloid may ensue on the site of very trifling lesions, c. g., leech 
bites, acne scars, scars from herpes, and all kinds of pustular 
and vesicular eruptions, and even from contusions, frictions, 
or blisters in which there is no cicatrix; indeed, one of the most 
extensive cases I know of followed an attack of prickly heat || 

* Annates de Derm, et de Syph., Vol. viii. (1897), p. 285. 

f An extreme case with colored illustrations is published in N. Y. Med. 
four., January 7, 1893. 

% Hebra, vol. iii. p. 278; three sisters and the mother were affected. 
Wilson, Hutchinson, and Bryant also mention cases. 

%Ch'n. Soc. Trans., vol. xiii., 1880, report on Dr. Goodhart's interesting 
casein the same volume, with plate; many of the facts above related are 
drawn from this report. See also Hutchinson, Med. Times and Gaz., 
May 23, 1885; and Archives, vol. iv., 1894. 

I Two cases of kelis by T. Longmore, Med. Chir. Trans., vol. xlvi., 
1863, illustrated. The disease affected the whole back in honeycomb 
bands, and there were also tumors on the chest and face. Hutchinson, 
loc. cit., mentions several instances of keloid nodules developing as a 
sequence of severely pruritic eruptions. He quotes Morrant Baker's case. 



KELOID. 



939 



in a soldier in India after the irritation had been present a 
month. It is evident, therefore, that the origin of many so- 
called false keloids may be overlooked, and they may errone- 
ously be considered to be spontaneous. While the existence 
of spontaneous keloid is not disputed, it is evident that it is 
futile to try and draw distinctions between it and scar keloid. 

Possibly the frequency of keloid on the sternum and mammae 
may be accounted for in women, by the pressure and friction 
of the stays, and in men by the frequency with which that region 
is exposed to similar influence, e. g., leaning against a desk, 
etc. I have observed scar keloid in association with the fol- 
lowing diseases: morphea, fibroma, and multiple fatty tumors, 
and appearing on the site of acne and vaccination and revac- 
cination scars. Several cases are on record of its occurrence 
in psoriasis without antecedent scarring (see that disease). In 
Anderson's case the keloids were quite white, and I have ob- 
served similar lesions on the back of a girl, but she knew noth- 
ing about their origin, and they were probably congenital. 

Pathology. — All that we know of the pathology is that it is 
a connective tissue new growth, intermediate in character be- 
tween a cicatrix and a sarcoma, commencing round the vessels, 
and ultimately compressing them and the other skin structures 
and forming a uniform collagenous mass. It is generally, if not 
always, connected with previous injury of the affected tissues, 
though the injury may be so slight as to be overlooked. 

It is evident from the etiology that pus cocci lesions are 
particularly liable to be followed by keloid, and the fact that 
when once keloid is started in a scar, old scars long quiescent 
may become keloidal is suggestive of microbic origin for the 
keloid itself. Probably also hypertrophic scars only occur in 
wounds which have not been aseptic. 

Anatomy. — Numerous observations on spontaneous keloid have been 
made by Langerhans,* Warren, Jr.,f Babes, and Deneriaz; % and upon 
scar koloid by Kaposi, Neumann, Schutz, and myself. 

Nos. 16 and 17, 1895. Catalogue of Skin Models, Coll. Surg., as an extreme 
example from urticaria. (See Urticaria Perstans Verrucosa, p. 162.) 

* Virchow's " Arch. Dritte Folge," Bd. xl., p. 334, with good resume of 
previous observations. 

\ "Sitzungsberichte, Akad. der Wissenschaften zu Wien," 1868, p. 413. 

% " These de la Faculte de Berne " (1887). A good detailed analysis in 
A1171. de Derm, et de Syph., vol. ix. (1888), p. 573. 



94° 



DISEASES OF THE SKIN. 



The first two observers found that in spontaneous keloid the tumor 
was imbedded deeply in the corium, and that the papillse and rete cones 
over it were intact, and hence they argue that it is a spontaneous new 
growth in the corium. The tumor consisted of dense bundles of connec- 
tive tissue, with the fibers running for the most part parallel to the long 
axis of the tumor and with the skin surface; here and there were some 
oblique bundles traversing the tumor; there were but few nuclei and 
spindle cells, and they were round the scanty vessels in the center of the 
tumor, but at the younger peripheral part both vessels and spindle cells 
were abundant. Warren also found the vessels affected far beyond the 
tumor, and these accounted for the recurrence of it after removal. Babes 
found that the papillae and cones were absent; either the tumor he ex- 
amined was really a scar keloid, or the papillae or rete cones were obliter- 
ated bv the pressure of the new growth. In scar keloid the papillae 




Recent scar keloid. 



a, a, a, bundles of delicate fibrils of new connective tissue; 
scattered through the connective tissue bundles. 



b, nuclei 



and rete cones are said to be absent, and Kaposi describes the same 
dense connective tissue, with few nuclei and vessels, as in the sponta- 
neous form. Deneriaz found giant cells in young keloid. 

The tumor I examined * had certainly not begun to form more than 
three weeks, springing up upon each side of a linear cicatrix, and per- 
haps from the holes made by wire sutures. Sections were made parallel 
and transversely to the long axis of the tumor. 

The papillae and rete cones were absent over the greater part of the 
tumor, but not over all, their presence or absence depending upon the 
depth of the tumor in the corium. When they were absent over the tumor, 
they were notably enlarged immediately beyond it. The rete was rather 
thickened over the tumor, the palisade cells were somewhat irregular in 
shape, but were in an even line below. Between the rete and the tumor 
there was a thin layer of highly vascularized, loose, connective tissue,. 

* Brit. Med. Jour., September 18, 1886, p. 544. 



KELOID. 94I 

with the vessels dilated and the fibers running transversely to the long 
axis of the tumor. In transverse sections the tumor was seen to be 
bounded below by fibrous tissue, compressed into a pseudo-capsule imper- 
fect at the sides. The tumor itself was freely traversed by branching 
dilated vessels which formed incomplete loculi, filled with cribriform 
tissue, but immediately round the vessel were fibers running parallel 
with it. In longitudinal sections the tumor was seen to consist of very 
delicate, sharply defined wavy fibrils or bundles of fibers, running 
parallel with the long axis of the tumor, and forming elongated meshes 
with the fusiform cells abundantly distributed between them; these cells 
were most abundant round, but not limited to, the vessels, which were 
less conspicuous than in the transverse sections. There were no signs 
of the appendages of the skin in the tumor, but outside it the hair 
follicles, sweat and sebaceous glands, were copiously infiltrated with 
round cells.obscuring or even breaking up their structure. The vessels also 
for a considerable distance, both beyond and below the tumor, reaching 
into the fat were also surrounded by round cells, were dilated, and their 
walls more or less infiltrated. In many of the sweat coils in the fat 
there was proliferation within, and infiltration between the acini. 

The above observations show that the papillae may be present over 
scar as well as over spontaneous keloid; and since Babes has shown that 
they may be absent in the spontaneous, and others have demonstrated 
their absence in the scar form, it is obvious that no argument, as to the 
origin of the tumor, can be founded on the presence or absence of the 
papillae or rete cones. Leloir, however, still upholds Kaposi that this is 
a valid mode of distinction. Vide also Unna's <4 Histopathology." I 
agree, however, with Hutchinson, that clinical facts do not support his 
statement, "that the keloid scar never extends with fibrous processes 
into the healthy tissue, for, being due to the granulation, it is only 
present in the neighborhood." Schiitz examined an old growth and 
found no elastic tissue and no cells. 

Diagnosis. — An apparently spontaneous scarlike tumor, with 
lateral clawlike processes, forming over the sternum or neigh- 
borhood, is so distinctive that error is scarcely possible. 
Whether arising on a scar or not, keloid differs from a thickened 
cicatrix by its extension beyond the limits of the original scar. 
The diagnosis between spontaneous and scar keloid is scarcely 
worth making; it generally depends upon the patient's state- 
ment as to its origin. In multiple spontaneous keloid, like de 
Amicis' and Vidal's cases, symmetry in the arrangement of the 
tumors would be an important distinction. 

Prognosis. — Spontaneous involution is not so rare as is 
usually stated; it is more likely to occur in the young, when the 
tumor is certainly of scar origin, and some say, in syphilitic 
scars, than when apparently idiopathic. As a rule, the tumor 



94 2 DISEASES OF THE SKIN. 

is slowly progressive up to a certain point, and then remains 
stationary for an indefinite time. 

Treatment. — This until lately was unsatisfactory; removal, 
however obtained, was almost invariably followed by return of 
the tumor. A very wide incision, so as to get beyond the dis- 
eased vessels, offers the best chance of success. Morphia or 
cocain injection is sometimes necessary when the tumor is very 
painful; belladonna or other anodynes locally applied may some- 
times be desirable. Quinine is recommended also for the pains, 
but is of doubtful utility; phenacetin and antipyrin; absorbents, 
both external and internal, are useless, but Verneuil is much 
in favor of pressure, and has even cured cases with the elastic 
bandage. Care must be taken to effect the pressure without 
friction, or the growth will increase. Vidal has produced great 
improvement, and even disappearance of the tumors, by multi- 
ple, deep linear incisions, mincing it up so as to divide the ves- 
sels as thoroughly as possible. The operation has to be re- 
peated many times, but from the first there was complete relief 
to the pains and irritation. Marie, however, after employing 
this procedure, observed an eruption of tumors of the same 
nature on points which had not been the seat of any wound or 
cicatrix. This led him to infer that a specific microbe had been 
introduced into the circulation by the scarifications. He there- 
fore injected oil with twenty per cent, of creasote. Under this 
the tumor became swollen and pale, followed by severe pain, 
which lasted for some hours. At the end of two or three days 
the tumor became violaceous, a vesicle formed on the surface — 
it passed into the state of dry scar. Balzer and Mousseaux have 
had equal success with it. Tousey of New York, R. C. New- 
ton, and Van Hoorn have had success by injecting a ten per 
cent, solution of thiosinamin either in alcohol, or better, as it is 
less painful, in equal parts of glycerin and water. I have had 
excellent results with this treatment. 

In an extensive hypertrophic scar all round the lower jaw 
from a burn, thiosinamin injections,* twenty minims for a dose, 
distributed along the growth produced great improvement, the 
tumor flattening, becoming less vascular, and therefore paler. 

* In a ten per cent, solution of thiosinamin some of it precipitates unless 
the solution is warmed just before injection. In the first case mentioned 
the treatment had not been completed at the time when this was written. 



KELOID. 



943 



Another case with bands across the elbow-joint was quite cured. 
The Rbntgen rays had an excellent effect in another such growth 
on the buttocks of a child of four from a scald. After fourteen 
exposures of a quarter of an hour each with three amperes, a 
vibrating interrupter, and the tube three inches away, inflam- 
matory reaction set in, and when this had subsided the growth 
had shrunk to a quarter of its original prominence, was pale, 
and no longer produced inconvenience when the child sat down. 
Herschel Harris of Australia* also had a successful case after 
fifteen sittings, a soft tube with six amperes, and the tube five 
inches away. This latter method of soft tubes and six amperes 
runs the risk of excessive reaction. A second series of eighteen 
sittings completed the cure in Harris' case. My experience 
leads me to rely most on thiosinamin injections and Rontgen 
rays. Thyroid extract administration has been used with suc- 
cess, but I have had no experience of it. Where the growths 
are numerous it would find its best application. 

Hardaway and Brocq advocate electrolysis by means of 
needles, this also evidently acting by occlusion of the vessels. 
The current should not be strong, and the needle not kept in 
long, or aggravation may ensue. If the positive pole, which 
coagulates better, is used, the needle must be of gold or irido- 
platinum. I have had some success with this treatment and 
can recommend it. A surgical needle curved on the flat and 
attached to the negative pole I have found best; it is passed 
under the growth, and a current of three amperes used for 
twenty to thirty seconds for each insertion. It is necessarily 
painful. 

* Abs. Brit. Jour. Derm., vol. xiii. (1901) p. 279. 



944 DISEASES OF THE SKIN. 

FIBROMA.* 

Deriv. — Fibra, a fiber. 

Synonyms. — Fibroma molluscum; Molluscum fibrosum; Mollus- 
cum simplex; Molluscum pendulum. Recklinghausen's 
disease, Neuro-fibroma. 

Definition. — Soft tumors, due to hyperplasia of the connective 
tissue of the deeper layer of the corium, and of the subcutaneous 
tissues. 

Fibroma Simplex. Synonym. — Acrochordon. Soft warts, "ver- 
mes charnues," are terms applied to the very common, from 
pin's-head to pea-sized, soft, pedunculated, vascular, and mole- 
like excrescences, which with their relics, in the shape of the 
empty hernialike sacs of skin, from which the contents have dis- 
appeared, are frequently seen upon the face, neck, and between 
the shoulders, and less frequently elsewhere in degenerated 
skins, chiefly of elderly people; but this is not the kind to 
which the term Fibroma is usually applied, and for which many 
dermatologists consider that Neuro-fibroma, or Recklinghau- 
sen's disease, would be more correct. This is a much rarer con- 
dition, only amounting to 9 in 16,863 American cases, and 1 in 
10,000 in my own and McCall Anderson's cases, though this 
probably underestimates the frequency, as such cases very often 
go to the general surgeon. 

There are three clinical varieties of this form: 1. Multiple 

* Literature .— Author's Atlas, Plate LXXIII., Figs. 1 to 4. Med. Chir. 
Trans., vol. xvi., Murray's and Pollock's cases, with colored plates and 
photos; ditto, vol. xxxvii. p. 155, V. Mott's cases, five cases with two 
portraits, small tumors. 1895 Cat. of Coll. Surgeons, Derm. Series, No. 
270 to 283. Cat. of Guy's Hosp., skin models 497 to 501. Clin. Soc. 
Trans., vol. xiii. p. 166, Sangster's case, engravings, histology, and 
many references; ditto, vol. vi. p. 160, and vol. viii. p. 138, G. Fritsche's. 
Hutchinson's Lectures, " Rare Diseases of the Skin," p. 196. Path. Soc. 
Cases, vol. xvi., Wright's case; vol. xxx., Wood's case by R. Royes-Bell; 
vol. vi., Beale's. Recklinghausen: " Ueber die Multiplen Fibrome der 
Haut," Berlin, i832 — an able and important monograph. " Skin Diseases 
in India," Fox and Farquhar's Rep., App. VI., p. 155; nine cases by Wise 
of Dacca, etc. R. W. Taylor, "Molluscum Fibrosum, and its Relation 
to Acrochordon and Keloid," Jour. Cut. and Gen.-Ur. Dis., vol. v. (1887), 
February and May. Walter Whitehead's case, Brit. Med. Jour., vol. i. 
(1902), p. 757, illustrated. 



FIBROMA. 945 

small soft tumors, in which the surface of the skin is almost 
unchanged; 2. Small tumors like the first variety, with large 
pendulous tumors (fibroma pendulum) ; 3. Fibroma pendulum 
without other tumors. 

Symptoms. — The tumors which constitute this affection are for 
the most part roundish or teat-shaped; they may be firm in 
parts, but are generally lax, so that the contents can, when 
pinched up, be rolled between the fingers. The skin over them 
is either tense or lax, usually smooth, and of normal color and 
surface, though sometimes bluish or pinkish from vascularity, 
w T hile those with constricted base are of a brownish or brownish- 
red hue; a hair sometimes, or one or more comedones, con- 
spicuous from their size, are to be seen in the center. In almost 
all other respects they present great variety. In number they 
may be from one or two up to hundreds and even thousands; 
in size they are from a pin's-head to an egg or an orange, or 
larger, but for the most part they do not exceed a walnut. 
They are round, oval, pyriform, or polypoid; some are im- 
bedded rather deeply under the skin, and are to be felt rather 
than seen; others are distinctly raised, but still sessile, and with 
a broad base like a mollusc; while others again have a pedicle, 
which becomes narrow eventually, and the tumor then hangs 
flabbily down, like a polypus. The tumors are quite painless, and 
give rise to no inconvenience except such as may arise from 
their position, unsightly appearance, or numbers. 

The trunk is the part of the body where they are most con- 
stant, in front more than at the back, while there are only a few 
on the sides. Next in frequency is the head, especially the oc- 
ciput, then the face and limbs, but they are seldom numerous on 
the latter, and they are rare on the palms and soles, where they 
become flattened by pressure. In a few cases the mucous mem- 
branes are involved,* especially the lips, gums, hard palate, and 
tongue. 

While in a small proportion of the tumors the contents be- 
come absorbed and leave an empty sac, as a rule they gradually 
increase f in number and size, but do not shorten life in any way. 

* In Walter J., U. C. H., there was a tumor on the buccal mucous mem- 
brane, and two on the side of the tongue. 

f Fig. 4 of my Atlas; loc. cit. y from a late photograph of the case of 
Plate XVIII., Syd. Soc. Atlas, showing enormous increase in numbers. 

60 



946 DISEASES OF THE SKIN. 

Sometimes when they have been absorbed a pseudo-tumor is 
left, the skin projecting and forming a slightly translucent 
bluish-tinted tumor, which under pressure with the finger dis- 
appears below the surface like a soft air-bladder.* 

Those tumors which are plexiform and obviously connected 
with nerve cords may be freely movable transversely, but very 
slightly in a vertical direction. They are especially found on 
the radial, saphenous, and crural nerves. f 

Irregular patches of brown pigment are frequently seen scat- 
tered about the body surface between the tumors, and there is 
freckling also, and in one of my cases the whole face had be- 
come darker. 

Besides this the skin is often coarse, thick, and pigmented; 
and hairy moles and vascular nevi and other skin deformities 
are common. 

When the tumors, instead of growing in their usual slow, 
almost imperceptible manner, develop rapidly, the skin contain- 
ing them becomes vascular, red, purplish, or mottled, then it 
excoriates, discharges, and ulcerates at the apex, and even 
sloughing may ensue; and when the growth is so rapid as to 
stretch and occlude the blood-vessels at the neck, which supply 
the tumor, the whole thing may slough off. Injuries such as 
friction, blows, etc., may produce similar results. 

Cases of soft fibroma of the palm are recorded by Sydney 
Jones, X R. W. Smith, and Hutchinson (Jones' case was in- 
closed within the dilated tendon sheath); and a case of hard 
fibroma of the prepuce by H. Perrin. 

Four remarkable cases under the title of Fibroma fungoides 
are related by Tilbury Fox,§ but they do not belong to the 
classes of tumors which are now under consideration. His sec- 
Plates LXIV. and LXV. of Hutchinson's smaller Atlas show face and 
back of the same man at a late stage. 

* Compare " multiple benign tumor like new growths," p. 649. And 
Prospelow's and Van Harlingen's so-called lymphangioma tuberosum 
multiplex cases were in all probability this form of fibroma. 

f Numerous acquired neuro-fibromata of firm consistence and of a quite 
different character to those of Recklinghausen's disease are recorded in 
the interesting treatise on Neuroma by R. W. Smith, Syd. Soc. reprint,. 
Fascic. xi. of Atlas of Illustrations of Pathology. 

% Sydney Jones, Path. Trans, vol. xxxviii. (1887), p. 323, with references. 

§ Tilbury Fox, p. 352, with illustrations of two of the cases. 



FIBROMA. 947 

ond case was probably a mycosis fungoides. His third was one 
of Murray's cases, and was possibly an early stage of the Som- 
mering-Behrend case * as far as the fingers are concerned. His 
fourth case suggested mycosis fungoides, but was said to be get- 
ting well under large doses of iodids. 

A fibromatous growth round the hair follicles of the back f 
occurs in nodules isolated or aggregated into an infiltration in 
association with adenoma sebaceum, with which it is described. 
Simple fibromata and the empty sacs left after their absorption 
are also common in that disease. 

The late stage of erythema diutinum elevatum has been re- 
ported as fibroma of the hands. Rare forms of fibromatous 
thickening of the skin are mentioned under Keloid. 

In the cases with pendulous tumors, which are much rarer, in 
addition to the ordinary tumors, there are others much larger, 
consisting of huge masses sometimes weighing many pounds. 
These tumors are always very lax; they may have a broad 
attachment, but always much less than their diameter, and they 
hang down in pendulous masses, often in overlapping folds 
like a coachman's cape, and between these folds there is often 
a serous fetid discharge. They feel simply like masses of skin 
and fat, and the skin, besides being lax, is coarse, often pig- 
mented, and covered with plugged sebaceous orifices. 

The favorite sites for the origin of these tumors are the 
occipital region, the sides of the neck, the face, arms and axillae, 
breasts, flanks, buttocks and thighs, and, according to Alibert, 
the eyebrows, abdomen, and labia. 

Instances of these remarkable tumors, in association with ordi- 
nary fibroma, are related by Bell,i: Alibert, § Virchow,|| Wright, 
Pollock, Roves-Bell, and many others, scattered through the 
medical journals. 

An extraordinary case of the kind was brought to the Patho- 

* Reproduced Hutchinson's smaller Atlas, Plates LX. and LXIII.; 
Author's Atlas, Plate LXXXVII., Fig. 2. 

\Med. Chir. Trans., vol. lvi. p. 234, with plate. They are reported 
as three cases of raolluscum fibrosum in children. 

% John Bell, " Principles of Surgery " (1808), vol. iii. 

§ Alibert. "Monographic des Dermatoses,' ' p. 796 (Paris, 1832), with 
plate. This is reproduced in Author's Atlas, Plate LXXIII., Fig. 3. 
Fig. 2 shows a huge tumor hanging from a man's side. 

I Virchow, "Die Krankhaften Geschwiilste," vol. i. p. 325. 



94 8 DISEASES OF THE SKIN. 

logical Society by Treves. I had an opportunity of examining 
the patient there, and at a show, where he was exhibited as an 
" elephant man." The bulk of the disease was on the right 
side; there was enormous hypertrophy of the skin of the whole 
right arm, measuring twelve inches round the wrist and five 
round one of the fingers, a lax mass of pendulous skin, etc., de- 
pending from the right pectoral region. The right side of the 
face was enormously thickened, and in addition there were 
huge unsymmetrical exostoses on the forehead and occiput. 
There were also tumors affecting the right side of the gums 
and palate; on both legs, but chiefly the right, and over nearly 
the whole of the back and buttocks; the skin was immensely 
thickened, with irregular lobulated masses of confluent tumors, 
presenting the ordinary molluscous characters. The left arm 
and hand were small and well formed. The man was twenty- 
five years old, of stunted growth, and had a right talipes 
equinus, but was fairly intelligent. The disease was not per- 
ceived much at birth, but began to develop when five years old, 
and had gradually increased since; it was, of course, ascribed 
to maternal fright during pregnancy. 

This condition may also occur without any of the small 
tumors, is more diffuse than the last class, and should then 
be called Fibroma pendulum instead of Dermatolysis,* or lax 
skin, as is usually done; it is often described as a separate dis- 
ease, but it is only an extreme end of a chain, in which the 
earlier links are wanting. The following case, which came 
under my observation some years ago, is a good example of an 
acquired condition: 

The patient was a storekeeper on a ship, aet. thirty-nine, and 
had fallen down the ship's hold fourteen years previously; a 
large abscess formed on the buttocks, and he was paraplegic for 
eight months; the abscess healed up, but continued to break 
out again at intervals. The buttocks began to increase in size 
two years after the accident, beginning at the sinus opening, and 
had gone on growing ever since; the leg began to enlarge ten 

* Valentine Mott called these tumors Pachydermatocele, but this term 
has also been used for elephantiasis Arabum. Ketley reports a *' flounce " 
case of the buttocks as " chalodermia" : Archiv f. Derm. u. Syph., vol. 
lvi. (1901), p. 108, illustrated; and there is an extreme case illustrated in 
<l La nouvelle Iconographie de la Salpetriere " (1902), p. 216. 



FIBROMA. 



949 



years after the accident. Enormous pendulous folds of skin 
and subcutaneous tissue overlapping like flounces, depended 
from the twelfth rib to about halfway down the thighs, forming 
huge rolls of lax tissue, which were freely movable in any direc- 
tion, and always took the most dependent position; there was 
a similar condition of the tissues of the right leg below the 
knee. The skin over the tumors was healthy-looking, but more 
pigmented than the rest of the body, and sensation was un- 
altered. The man was of short stature, but intelligent, and his 
general health was good, except that he had shooting pains in 
the right leg, and in various parts of the tumor. There were 
no ordinary fibroma tumors, but from time to time small 
tumors, the size of a bean, appeared in the abdominal wall; the 
skin over them was reddened, and they did not burst externally, 
but, when he squeezed them, they ruptured internally, and dis- 
appeared at once. Sensibility was not diminished over the 
tumor as it is in some cases. 

In another, a somewhat similar condition of hyperplasia of 
the subcutaneous tissue, but less developed, and not so lax, was 
limited to the palms, soles, sides of neck, nose, and tonsils, in 
the last part necessitating excision. This condition supervened 
after scarlet fever, but there was no evidence of albuminuria * 
either past or present. These cases, it is to be noticed, came 
on later in life, but differ only in their origin from the others 
which begin in early childhood, such as Valentine Mott's or 
Fritsche's cases. J. Cowan f describes two cases of hypertrophic 
folds of the scalp in idiots. Also Cazenave's Atlas, Plate 
XXXVII. 

There are also congenital cases where there is loose attach- 
ment of the skin without hypertrophy, and it is to these 
that the term Dermatolysis, should be restricted. In 1657, a 
Spaniard, £ Georgius Albes, is reported to have been able to 
draw the skin of the right pectoral region to the left ear, or the 

* Shown at Clin. Soc. by Balance and Hadden, January 25, 1885. 

f Journal of Mental Science, October, 1893, p. 539, with plate. 

^Related in Job A. Meek'ren's Observationes Medico-Chirnrgicce 
(Amstel., 1682), chap, xxxii., " De Dilatabilitate Extraordinaria Cutis," 
with engraving. Quoted in John Bell's " Surgery," vol. iii. (1815), p. 36, 
and in Coll. of Surg. Museum Dermatological Catalogue, 1895, No. 287, p. 
96. Ohmann-Dumesnil reports three cases of " elastic skin," but not so 
extreme as the above, hiternat. Med. Magazine, vol. i. (1892), p. 244. 



95° 



DISEASES OF THE SKIN. 



skin under the chin over the face to the vertex, while the skin 
over the knee could be extended half a yard, and it retracted 
to its normal position, and was not in folds; this mobility was 
limited to the right side. An " elastic-skinned man " was ex- 
hibited in London in 1882. Another case of a young man, set. 
nineteen, is reported by Seiffert, who examined some skin from 
over the left second rib, and found that, contrary to Kopp's 
supposition, the elastic fibers were quite normal, but that there 
was a transformation of the connective tissue of the dermis into 
an unformed tissue like a myxoma, with total disappearance of 
the connective-tissue bundles. This brings it into relationship 
with fibroma, in which this ill-formed gelatinous connective 
tissue is a marked, feature. Laxity of the skin after distention is 
often seen in multiparas, both in the breasts and abdominal 
walls, from obesity, etc., and to a slighter extent in the de- 
generated skin of old age, but in all these the skin falls into 
folds. 

Etiology. — Heredity * and, occasionally, congenital predisposi- 
tion are the only positive causes assignable. 

Fibroma occurs in both sexes and in various races, begin- 
ning often in the early months of life, and nearly always in 
childhood. It has no effect upon vitality, may be seen at every 
age, and in all stages of development, though the tumors are 
seldom large in early life. 

Fibroma pendulum alone is more frequently acquired in later 
life, and in the case related was the result of injury and sup- 
puration; instances of localized fibroma, the result of injury, 
have also been related by Schwimmer and by Taylor of New 
York;f but the cause cannot be traced in most cases. The 
Chinese are said to be more liable to it than other nationalities, 
and in them the tumor may attain to an enormous size. 

* Virchow's cases — quoted by Hebra, vol. iii. p. 341, father, grandfather, 
brothers, and sisters affected; Ochterhony's case, American Arch. Der?n., 
July. 1875, of a negro woman and her child; and Atkinson's cases, A T ew 
York Med. Jour., vol. xxii. (1875), p. 601, of a brother and sister affected, 
who said that their father had some kind of tumors — may be referred to. 
See also Wise's cases in Fox and Farquhar's " Tropical Skin Diseases." 
App. VI., p. io8, and Wagner's " General Pathology," p. 383, in which a 
father and son were affected. 

f Taylor, " Molluscum Fibrosum and its Relation to Keloid, etc.," Amer. 
four. Cut. Dis., vol. v. (1887), p. 161. Also p. 41, on "Development and 
Course." 



FIBROMA. 95 1 

All Hebra's cases were in individuals " stunted in bodily 
growth, and of more or less defective mental capacity." This is 
true of the majority of cases, but there are many exceptions. 

Pathology. — The most probable theory is that the disease 
originates in some congenital defect of development of con- 
nective tissue, though the tumors may not reveal themselves for 
years. 

In 1882 von Recklinghausen * stated that the soft tumors 
were formed by the overgrowth of the inner lamellar sheaths of 
the nerve cords, the outer dense layer of the nerve sheath not 
being involved; that, originally springing from subcutaneous 
nerve trunks, they grew upwards still along the nerves round 
the sweat coils and other appendages of the skin and the coats 
of the blood-vessels. The connective tissue thus derived is 
soft and transparent, and different from the connective tissue of 
the skin. Krieger, Unna, and others confirm these observa- 
tions, and point out that this explains the frequent plexiform 
arrangement of the deeper tumors. While the papillary layer 
and epidermis are usually unaffected, the appendages of the 
skin are more or less modified by the neoplasm, either by con- 
striction or stretching, but the nutrition of these organs is unaf- 
fected, though their connective tissue is gradually replaced by 
that of the new growth. 

Unna thinks that any congenital or nevoid growths are com- 
plications, and do not belong to the neuro-fibromata. Unna 
does not admit that these neuro-fibromata are of congenital or 
nevoid origin, but that they are " true acquired fibromata "; but 
clinically these growths are so mixed up and often show them- 
selves very early in life, together with other admitted con- 
genital deformities, that they cannot be logically separated, and 
most authors admit their congenital origin. 

In the pendulous tumors, especially in those which have fol- 
lowed injury, the presumption is in favor of their being largely 
due to the obstruction of the superficial lymphatics, at least in 
the diffuse cases, but we are entirely ignorant as to how the 
obstruction arises. This theory, and many points in its anat- 
omy, bring it into pathological relationship with elephantiasis 
Arabum, though there are many striking clinical differences. 

* Loc. cit., and Unna's " Histopathology," p. 844, and references. 



952 



DISEASES OF THE SKIN. 



The " keloid en plaques " of Taylor and Hutchinson are in 
Unna's view " a simple fibroma cutis." 

Anatomy. — On section, the substance of the tumor is found to be made 
up of more or less imperfectly developed fibrous tissue, from which a small 
quantity of clear, yellow fluid can be pressed out. In a medium-sized 
tumor the fibrous tissue is firmest and most developed at the base and 
in coarse bundles; in the center it is loose and gelatinous, and at the 
periphery fine and delicate, like the normal corium, of which the papillary 
layer and its epidermal covering are quite unchanged. It must not, how- 
ever, be supposed that there is any abrupt transition from the firm to the 



&-M 




Fig. 54. — A pin's-head-sized tumor or fibroma X 50, composed of gelatinous 
tissue, a, portion of sweat duct; 6, hair follicles; c, another tumor; 
d, d, large vessels supplying the tumors; e, sebaceous gland;/", 
fibrous tissue of corium. 

gelatinous tissue. In a very young or small tumor, the whole contents 
may be gelatinous, while in an old or very large one t^ere will be much 
perfect and compact, but coarse, fibrous tissue, with fine fibers between the 
meshes, but very little gelatinous tissue. Between the layers are cells 
with large, strongly refracting nuclei, and the cells may be in strata, foci, 
or scattered between the bundles; they are most abundant where the 
gelatinous tissue predominates, and are therefore comparatively scanty in 
the old tumors. Large vessels enter and leave the tumor at the base, 
and terminate in fine capillaries at the periphery. The condition of the 
glands has already been alluded to. 

The above description was made from tumors of my Atlas case many 
years ago. and, though true as far as it goes, more modern staining methods 
show that, according to Unna, a peculiar variety of mast cell must be 
added as "the most striking constituent." They are pretty regularly 



FIBROMA. 953 

distributed and are numerous in the larger nodules. There are some 
ordinary mast cells, and others which with the polychrome methyl blue 
show a regular dense oval halo staining red, and about double the size of 
the contained mast cell with its small blue nucleus. 

Diagnosis. — 'When there is a large number of soft sessile or 
pedunculated tumors on the trunk there can be no difficulty 
about the diagnosis. 

Multiple fatty tumors have but slight resemblance; they are 
flatter,, generally lobulated, never pedunculated, and do not 
project in the globose way that the majority of the fibroma 
tumors do. 

From soft moles, the fact of moles being congenital would be 
sufficient; they, too, are nearly always pigmented. When few 
in number the tumors which grow between the shoulders in 
elderly people are very like them, and for practical purposes it 
may be considered that they are the same. One difference is 
generally present in the latter, viz., an alteration in the epi- 
dermis, which only occurs in fibroma when it has been inflamed. 

In sebaceous cysts the sebum can be pressed out in large 
quantities, and the sac partly emptied, while in fibroma a large 
comedo is the most that can be squeezed out, and often nothing 
at all. 

The cysticerous cellulosce cutis gives rise to subcutaneous pea 
to hazelnut-sized tumors, which are so hard that they are often 
regarded as fibrous tumors. Their great mobility, obvious sub- 
cutaneous position, scattered distribution, and clearly uniform 
size and hardness, the age of the patient when they com- 
menced, as they would be unlikely to occur in childhood, are all 
points suggestive of their character, but their extreme rarity 
makes one forget the possibility of their existence. 

Prognosis. — The tumors will almost certainly increase in num- 
ber and size, though generally very slowly. They are merely 
inconvenient from their size and position, and are never dan- 
gerous to life. 

Treatment. — Those that are pedunculated can be removed by 
ligature, the galvanic cautery, or the ecraseur. The rest may 
be excised if they are not too numerous, but the removal must 
be complete. 

Keloid has followed excision in several instances, including 
one of my own. (See Keloid.) 



954 DISEASES OF THE SKIN. 

Whitehouse * gave three Asiatic pills a day for three months, 
when large numbers of tumors disappeared, and after increas- 
ing the number to four or five, at the end of seven months half 
the original number had disappeared. 

In the dermatolytic cases, where a part only of a tumor has 
been excised, it has regrown; but where complete ablation has 
been practiced there have been several successful operations 
without recurrence, even with very large masses, such as Mott's, 
Kosinski's (thirty-five pounds), Pollock's, Stokes', John Wood's 
cases, and others. Care should be taken to secure the vessels 
before they are cut, as the bleeding may otherwise be very 
formidable, especially in the large tumors. 

NEUROMA. 

Deriv. — vavpov, a nerve. 
Synonyms. — Nerve tumor; Fr., Nevrome. 

The tumors of the skin, thus designated, are really fibro- 
neuromata, and consist, for the most part, of firm connective 
tissue, starting from the neurilemma, with non-medullated 
fibers over, but seldom within, them. Only two instances in 
which they affect the skin primarily are on record, viz., by Duh- 
ring and Kosinski, the " painful tubercles " f of Wood and 
other so-called instances of neuroma and fibro-neuroma of 
Recklinghausen, Kobner, and others being really subcutaneous. 

The two cases alluded to were both men: Duhring's,J set. 
seventy, and Kosinski's, § set. thirty. In the first they had been 
developing for ten years, in the second for fourteen. They af- 
fected, in one case, the left scapular region and the arm to the 
elbow — i. e., branches of the circumflex chiefly — and in the 

* Amer. four. Cut. and Gen.-Ur. Dis., vol. xvii. (1899), p. 583. 

\ Under the " Tuberculum dolorosum" cases of different structure are 
recorded, vide Unna's " Histopathology," p. 850. For other neuromata, 
svide R. W. Smith's "Treatise," toe. cit., also "Neuroma and Neuro 
fibromatosis," by Alexis Thomson (Edinburgh, 1900), 4to. 

^International Atlas, Plate XXXV. It was previously published in 
Amer. [our. Med. Sciences, October, 1873, as a " Case of Painful Neuroma 
of the Skin." 

§" Neuroma Multiplex," Centralblatt fur Ckirurgie, No. 16, 1874. 



MYOMA. 



955 



younger man, the outer and upper two-thirds of the thigh and 
the buttock — i. e., the small sciatic and external cutaneous. 
The tumors were flat, firm nodules, from a pin's head to a split 
pea or a hazelnut in size, confluent and disseminated, imbedded 
in the skin itself, and therefore movable only with it. The skin 
between the nodules was normal when pain was absent. The 
tumors were not painful at first, but became so afterwards, espe- 
cially on pressure, which, in Kosinski's case, sent the pain 
radiating in all directions; while, in Duhring's, violent paroxys- 
mal attacks of pain, shooting down the arm, occurred, during 
which the affected area became hotter and violaceous in color. 
In his case also there was slight scaliness over the nodules. 
Comparison with Hardaway's case of multiple myomata shows 
great clinical resemblance. Microscopically, in Duhring's case, 
the tumors w r ere found to be in the skin, and " consisted essen- 
tially of the elements of the skin, densely packed connective tis- 
sue from medullated nerve fibers." It agreed with Virchow's 
description of amyelinic neuroma. 

In both instances immediate relief from the pain was ob- 
tained by removing a portion of the nerve supply, the brachial 
plexus, and small sciatic respectively, which was followed by 
gradual subsidence of the tumors. Unfortunately, in Duhring's 
case, immunity only lasted six months, and within a year the 
pain was progressively returning, and in two years was as bad 
as ever. He lived six and a half years after the operation, 
dying at eighty-two without further change in the skin. 

MYOMA.* 

Deriv. — javS, a muscle. 

Synonym. — Dermato-myoma. Muscle tumor. 

From a pathological standpoint dermato-myomata may be 
divided into those of superficial and those of deep origin, which 
practically corresponds to the clinical subdivision into single 
and multiple. 

* Literature. — Brit. Jour. Derm., vol. ix. (1897), pp. 1 and 47; a case of 
myoma multiplex by the author, with colored plate. Abs. of all cases to 
date, with references and critical observations. Neumann's case was 
published contemporaneously in Archiv f. Derm. ti. Syph., vol. xxxix. 



956 DISEASES OF THE SKIN. 

The multiple tumors, though rare, as there are a little over 
a dozen indisputable cases on record, are the most interesting 
to the dermatologist, and will be considered first. Besnier 
(1880) was the first to describe a living case, and to give a clear 
account of the disease. 

The individual lesions vary from a millet seed to a hazelnut, 
but few are larger than a pea. The color is usually brownish- 
red, or some other shade of red removable by pressure, but in 
Hess' and Lukasiewicz's case it was yellowish, and even trans- 
lucent. The surface of the skin over the tumors is always nor- 
mal, the texture firm; they are in the skin, and freely movable 
with it over the subjacent parts. While they may be isolated, 
there is a strong tendency to group with or without coalescence, 
sometimes amounting to an infiltration. The groups may form 
into irregular patches, lines, or bands; but wherever there is an 
interval, the intervening skin is normal. The numbers of the 
tumors is very variable, sometimes being innumerable (Verneuil 
and Besnier), or they may be in moderate numbers and with a 
very limited distribution, the latter being the rule. 

In Hardaway's, Hess', and my first case there was only a 
single patch, but where there are more there is no symmetrical 
arrangement, either in the groups or isolated lesions. Further, 
there is no special localization, as they occur on the upper and 
lower limbs, while the trunk, neck, and face (four cases) have 
been attacked in different instances, while in Verneuil's all the 
regions of the body were involved; but some authors exclude 
Verneuil's case and that of Brigidi and Marcacci. 

The new growths develop very slowly and at first singly, but 
with a tendency to constantly increase both in size and number. 
There has been no antecedent lesion, except in Brigidi and 

(1897), p. 3, also with colored plates. See also Besnier-Doyon's Kaposi, 
vol. ii., notes, p. 346. T. von Marschalko has published a case in a man, 
set. twenty-eight, in whom it began eight years previously, and quite 
suddenly, he said. It began with itching, and was followed by pain and 
tenderness; pinching them up gave intense pain. They were closely 
aggregated in a large area on the right leg, where there were one hun- 
dred nodules, while on the left thigh were about fifty more scattered. 
The size was from a pin to a split pea. Monatsh. f. prakt. Derm., 
October >qoo, p. 313 Abs., Brit. Jour. Der?n., vol. xiii. (1901), p. 68. 
In Leslie Roberts' case, which also came under my observation — the 
lesions -ere small, nei-sized and smaller, on the cheek of a lady, ast. 
eighteen, Brit. Joicr. Derm., vol. xii. (1900), p. 117. 



MYOMA. 957 

Marcacci's case, in which swelling of the part was the first 
sign observed. Sooner or later there was pain in half the 
cases, the rest having been painless throughout. The pains are 
usually spontaneous, paroxysmal, and severe, lasting from min- 
utes to hours; but they can always be excited by strong pres- 
sure, and sometimes by changes of temperature, especially by 
cold. 

These pains develop gradually, being absent until the tumors 
are the size of a pea or larger, but in Hardaway's case pain in 
the region in which the tumors subsequently appeared was the 
first symptom to attract the patient's attention. Itching was 
present in one of Jadassohn's cases, and preceded the pain in 
Marschalko's case. 

Microscopical examination makes it probable that the pains 
are due to pressure on the nerve-endings outside the tumors. 
In other respects the tumors are always perfectly benign, never 
infect glands, and never recur after excision, but the pain has 
not been relieved in all cases by the operation. 

Of thirteen cases, nine were females and four males, and the 
age at which the tumors began to develop varied from infancy 
(Hess' case was probably congenital) to sixty years. 

Wolters reports two cases from Doutrelepont's clinic which, 
on microscopical grounds, he claims to be dermato-myomata, 
but my reason for excluding them from this group are given in 
my paper referred to. Clinically they correspond to xanthoma 
multiplex. 

Morris has shown two cases at the Dermatological Society, 
one in a man of fifty-four, the other in his daughter, set. about 
twenty-five. The tumors were painful, and the general appear- 
ance was like Lukasiewicz's case. 

Pathology. — The bulk of the tumors is made up of smooth, 
muscular fibers, derived in most cases from the arrectores 
pilorum, but in Hardaway's and Hess' cases they were derived 
from the muscular coat of the vessels. In my case the tumors 
were in the corium round the hair follicles, but did not actually 
alter them, but invested them with a thick layer of smooth, mus- 
cular fibers, which also separated the acini of the sweat and 
sebaceous follicles; the muscular coats of both arteries and 
veins were conspicuously thickened. 

Diagnosis. — The most constant features are their slow pro- 



958 DISEASES OF THE SKIN. 

gressive development in number and size; the tendency to 
group; their unsymmetrical distribution; the fact that they are 
seldom larger than a pea; their dull red or yellowish color, firm 
consistence, and mobility over subjacent surfaces, and their 
strong tendency to ultimately become severely and paroxys- 
mally painful; in this and their close grouping resembling true 
neuroma. Most of the cases have not been diagnosed until 
a microscopic examination has been made. Thus: 

Lesser * diagnosed one case of lymphangioma as dermato- 
myoma, but the microscope showed its real nature. That it is 
often no easy matter to decide the nature of cutaneous and sub- 
cutaneous nodules is shown by the observations of Chantelux. 
In four cases in which nodules were excised and examined, one 
was a papillary fibroma of a sweat gland, another was a tubular 
epithelioma of a sweat gland, a third was a subungual corpus- 
cular neuroma, while the fourth was a fibromyoma of the inner 
side of the ring finger. In my second case I diagnosed it as 
lymphangioma-like nodules, probably adenomata. 

Treatment. — When not too numerous and over too wide an 
area they may be excised without fear of return, or if quite 
small they may be destroyed by electrolysis. 

The more deeply seated leiomyomata (smooth muscular 
tumors) arise from the deep muscular layer of the skin, or from 
embryonic remnants, or reach the skin secondarily. They are 
mostly but not always single, are more common than the super- 
ficial form, and chiefly concern the general surgeon. Cases have 
been reported by Virchow, Forster, Klob, Sokolow, S. Marc, 
etc. 

They may be sessile or pedunculated, from an almond to a 
walnut in size, as a rule, but may be as large as an orange. 
They occur chiefly on the mammae and the male and female 
genitalia (in Passalacqua's case it was on the crest of the tibia) r 
are contractile on exposure to cold, vascular, slow-growing 
tumors, and usually painless, but were intensely painful in 
Virchow's case.* They consist mainly of involuntary muscular 
fibers, but may contain much fibrous tissue and form a 
fibromyoma or be highly vascular, cavernous and erectile, 

* Virch. Archiv, Bd. 123, Heft. i. 

f In Virchow's case, in 1854, about a dozen developed about the nipple 
of a man. 



N2EVUS PIGMENTOSUS. 



959 



constituting angiomyoma, or, if the lymphatics are involved, 
lymphangiomyoma. The angiomyomata are more frequently 
multiple than the rest, and are said by Babes to be derived from 
the arrectores pilorum. Ablation is the only remedy. 

N^VUS PIGMENTOSUS. 

Synonyms. — Pigmentary mole; Naevus spilus; Fr., Naevus pig- 
mentaire; Ger., Fleckenmal; Pigmentmal; Naevus pigmen- 
tosa; Linsenmal. 

Definition. — Congenital pigmentary deposits, with or without 
other changes in the skin. 

Symptoms. — Moles may be simply collections of pigment in 
the skin, without any other change (naevus spilus). These are 
generally quite small, not larger than a large lentil, are most 
common on the back, but may be seen elsewhere. They some- 
times develop into moles of the usual character. Hebra con- 
siders that they are really not congenital, and therefore ought 
not to be called nevi, but it is impossible to distinguish those 
present at birth from those formed subsequently. They are 
often mistakenly classed with lentigo. 

Another form of mole is more or less raised, and the surface 
is furrowed or otherwise uneven, and may be rough and warty 
in character (naevus verrucosus), or covered with soft papil- 
lary growths (naevus papillomatosus). The secretion from the 
papillary mole is often offensive. Some of the large ones are 
soft and lax, containing a quantity of fat and loose connective 
tissue, and resemble dermatolytic growths (naevus lipoma- 
todes). A large proportion of moles possess a growth of more 
or less dense, dark, or less frequently lanugo-like hair (naevus 
pilosus). The color of moles varies from a cafe-au-lait 
tint to dark brown or black; occasionally, as Hutchinson has 
pointed out, growths precisely similar to raised moles exist 
without any pigment or perhaps are only a very pale fawn color : 
he calls them " white moles." * A very large, corrugated, cere- 
belliform, unpigmented growth of this kind on the side of the 
face, with smaller growths on the neck and chin, was sent to me 
by my colleague, Mr. Pollard. A very large, unpigmented, cere- 
* Author's Atlas, Plate LV., Figs. 2 and 3. 



9 6o DISEASES OF THE SKIN. 

briform mole, covering the occipital region, is figured and de- 
scribed by Mansell Moullin.* 

Moles vary infinitely in size, number, and distribution. The 
face, neck, and back are the favorite positions. Occasionally 
they have a traceable nerve distribution, f or they may occupy 
the intermediate zone between two neighboring nerve areas 
(Voigt's lines). Others again appear to have a metameric dis- 
tribution, or that of the blood-vessels, while in the majority no 
systematic distribution is traceable. 

In number they may amount to hundreds, scattered all over 
the surface, and while the majority are under half an inch, they 
may occupy whole regions. A distribution which has been 
observed in several instances J is the lower part of the trunk 
extending higher behind than in front, and going down nearly 
to the lower end of the thigh, compared to the position of 
" bathing tights." Whether, as in lumbar hypertrichosis, there 
is any connection with concealed spina bilfida, is worthy of in- 
vestigation. They may grow in proportion to the growth of 
the bearer, become more prominent and hairy, but they seldom 
extend at the border; thus in a very extensive mole on the arm 
of a woman, set. forty, sent to me by Mr. Cursham Corner, § the 
mother stated that up to the age of five years it was brown 
and smooth, and that it then began to get papillary, more 
prominent, and with a black horny covering, but it had never 
extended at the border. I have, however, seen several in- 

* Brit. Med. Joar., January 31, 1891. 

f See T. Okamura, " Zur Kenntniss der Systematisirten Nsevi und ihres 
Ursprungs," Archiv f. Derm. u. Syph.,vo>\. lvi. (1901), p. 352. Illustrated. 

% A Peruvian boy was shown at the Westminster Aquarium with a dark 
hairy mole with this distribution, and Nevins-Hyde records and figures 
two similar instances with dermatolytic growths in Jour, of Cut. and 
Ven. Dis., vol. iii. p. 93; also a case of multiple lateral nevi in bands in 
Chicago Med. Jour, and Examiner, October, 1877. The sister of the 
above Peruvian boy had a still larger growth, extending from the nucha 
all over the back. Both she and her brother had hundreds of smaller 
hairy growths of all sizes scattered irregularly over the trunk, face, and 
limbs. A still more extraordinary case, with extensive dermatolytic 
growths all over the back, and nevi of all sizes elsewhere, is described 
and figured in Lavater's " Physiognomy," 1848, ed., Plates LXI. and LXII. 
See also Paget's case, Lancet, August, 1867; Ziemssen's " Handbook of 
Skin Diseases," p. 405. 

§ Depicted in Plate LV., Fig. 1, Author's Atlas. 



N&VUS PIGMENTOSUS. 961 

stances of extension of moles even in young persons, and 
Hutchinson* records a case where a mole on the side of the 
head spread at the margin in an adult. This extension is espe- 
cially liable to occur in the flat moles which often cover a large 
area, project very slightly above the normal level, and are 
quadrillated by the deepened natural lines. They are usually of 
a pale brown color, and in a .case of Colcott Fox's f occupied 
almost the entire vertical half of the body, like some cases of 
ichthyosis hystrix. In a similar case of Sequeira's, epithelioma 
developed at the age of forty-nine. Late in life, moles, espe- 
cially if irritated in any way, are sometimes the starting-point 
of melanotic forms of malignant tumor. The melanotic 
growths are especially liable to start from moles on the foot. 
They were formerly called melanotic sarcoma, but J. Hutchin- 
son, Jr., Unna, Gilchrist, and others % have shown that moles 
are epithelial growths, and that the malignant growths there- 
fore are cancers, not sarcomata {vide Melanotic Sarcoma). For 
this reason, a mole which shows signs of activity in an elderly 
person should be removed at once. 

When not too large, and if they are disfiguring from their 
position, moles may be removed by the knife § or caustics, not 
taking away the whole depth of the corium if it can be avoided. 
Small growths can be destroyed by electrolysis, and hairs on 
moles may be permanently removed by the same method. 

If the hair growth is very extensive the Rontgen rays may 
be used, as in such cases the disfigurement is so great that the 
small risk of a Rontgen ray burn may be justifiably incurred. 

* Hutchinson's Archives of Stirgery, vol. ii. p. No. 8, p. 366. 

f Brit. Jour. Derm., vol. ix. (1897), p. 446. 

% See a paper by Whitfield with good resume of the subject, Brit. Jour. 
Derm., vol. xii. (1900), p. 267. 

§ See a case of removal of mole occupying half of the forehead by Morrant 
Baker in Med. Chir. Trans., vol. lxi. Eve also removed a mole almost as 
large for a patient of mine, a young man, in whom a mole of the orbit and 
supra-orbital region was actually extending. 



61 



962 DISEASES OF THE SKIN. 

N^VUS VASCULARIS. 

Synonyms. — Naevus vasculosus; Naevus sanguineus; 
Ger., Gefassmal. 

Definition. — A congenital overgrowth of cutaneous vascular 
tissue. 

Vascular nevi are divided into capillary or cutaneous, and 
venous or subcutaneous, but the .latter may involve the skin 
as well. 

Symptoms. — They present immense variety in size, from a 
pin's point up to a large tract, involving the greater part of a 
limb or region. 

They are nearly always flattish, but may be on a level with the 
skin, or more or less raised above it; they are roundish or 
irregular in shape, of a uniform or lobulated surface, this de- 
pending upon whether they consist of capillaries, or large veins, 
or vascular sinuses, and the amount of intermediate connective 
tissue; their color is from a bright red to a deep purple. 

The most common seat of the capillary nevi is on some part 
of the face, head, neck, or arms, but they may come in other 
places. They may be very small at birth, and increase up to the 
size of a crown, or less; and may then either remain stationary 
for the rest of life, or gradually undergo involution and disap- 
pear, leaving atrophic scars, either white or pigmented. Ac- 
cording to Depaul, one-third of the children born at the Clinique 
de la Faculte de Medecine at Paris have them at birth, but most 
of them disappear within a month; but few authors go so far, 
either as to the frequency of their occurrence or their disap- 
pearance. 

The capillary nevus is the most common, and is usually 
moderately elevated and of bright color. Another form is of a 
diffuse, very slightly, if at all, raised, red, or purplish-red patch 
or patches on some part of the face, often involving the whole 
of one side ; this is the well-known " port-wine mark," or naevus 
flammeus, the Feuermal of the Germans and Tache de feu of 
the French. In one of my cases * it occupied the right side of 
the face, but on the trunk and limbs extended over nearly 

* Author's Atlas, Plate LVII., Figs. 3 and 4. 



N2EVUS VASCULARIS. 963 

three-fourths of the surface. In a case of Pollitzer * it was 
punctiform and nearly universal except on the head and face. 

The venous nevus is more raised than the capillary, often 
clearly defined, convex, smooth, or lobulated, of a dark purple 
color, very soft, inelastic, and compressible, unless inflamed and 
containing cysts, but filling again immediately. Such nevi oc- 
cur chiefly on the lower part of the body, about the back, nates, 
pudenda, and lower limbs, but are not very unusual on the neck, 
beneath the lower jaw. They vary from half a walnut to an 
orange in size; the skin over them may be normal, or there may 
be capillary dilatation here and there. Some of these nevi are 
turgescent, erectile, or pulsating. 

Anatomy. — Capillary nevi are simply capillaries increased in size and 
number, and closely aggregated. 

Venous nevi are circumscribed and composed of thin-walled veins and 
sinuses, bound together with delicate connective tissue, and a few small 
arteries which run directly into the venous sinuses, without the interven- 
tion of capillaries. 

Diagnosis. — This seldom offers any difficulty, except the faint 
nevi which are so common on the scalp, especially in the lower 
occipital region, and are usually discovered accidentally. They 
are easily mistaken for slight degrees of inflammation, espe- 
cially when their existence has not been thought of. The prog- 
nosis is uncertain, many of the capillary form disappearing 
spontaneously, but many more increase in size up to a certain 
point, and then remain unchanged. Others ulcerate spontane- 
ously, beginning in the center and spreading towards the 
periphery. There is no pain, and the ulceration is indolent and 
superficial, with scanty viscid discharge, which dries up into a 
scab, and when this comes off a thin scar replaces the nevus 
tissue; in other words, the nevus is cured. According to 
Stephen Paget, those nevi which are only slightly raised, ill- 
defined, and pale, are the most likely to ulcerate. The port-wine 
mark is usually stationary from beginning to end, but I have 
known it increase, f even in adults. On the other hand, I have 
seen a case in which at birth there was a crimson-tinted capil- 

♦Internat. Atlas, Fascic. xiv., Plate XLII. 

f Francis' case of angioma serpiginosum, Plate XXXIV., Internat. 
Atlas, appears to have been a growing port- wine nevus. 



964 DISEASES OF THE SKIN. 

lary nevus which occupied almost the whole of the face below 
the orbit except round the mouth and chin. When between 
thirteen and fourteen it began to disappear, and at eighteen 
there was only a palm-sized patch on each side in front of the 
ear and a narrow band across the nose. 

Treatment. — Those that are small and superficial, not in a con- 
spicuous position, and not growing larger, may be left alone, 
and there is a good chance of their disappearing spontaneously, 
and this tendency may be assisted by painting on collodion 
or the liquor plumbi subacetatis, collodion, from its compress- 
ing action, being preferable, or, if over a bony part, mechanical 
compression may be employed. Large port-wine marks cannot 
be successfully dealt with. B. Squire claims that repeated linear 
scarification will remove them without subsequent scarring; but 
neither have others obtained such results, nor have two of his 
own cases that I have seen been successful, one after more than 
fifty operations showing no improvement, the mother thought, 
though where nitric acid had been applied there were white 
scars. Duhring gives very much the same verdict with regard 
to Sherwell's multiple puncture method. In the extensive case 
mentioned above I obtained some improvement by means of 
electrolysis, passing a fine needle under the skin in closely ar- 
ranged parallel lines. The methods employed to remove ordi- 
nary nevi come into the following categories: 1. To produce 
plugging within the vessels by exciting inflammation or by elec- 
trolysis. 2. To destroy the growth by caustic or the cautery. 
3. To remove it by the knife or ligature. 

When the nevi are small, or in such a position on the face that 
the kind of scar is of importance, inflammation, electrolysis, or 
excision may be employed. One method is by vaccination, 
which answers well for nevi of moderate size, several punctures 
being made carefully, so that the lymph is not washed out by 
the bleeding. Another plan is to pass some fine silk threads 
through it in various directions, until some inflammation is ex- 
cited, repeating this as often as it is necessary for the occlusion 
of all the vessels. Injection with perchlorid of iron, chlorid of 
zinc, or tannin is effectual, but dangerous, unless great care is 
employed to prevent any coagula getting into the general cir- 
culation. This may be done by isolating the growth by a liga- 
ture applied for a few minutes before and after the injection. 



NJEVUS VASCULARIS. 965 

Electrolysis is, however, preferable, as it is never advisable to 
run the smallest risk for such a trivial cause. 

When electrolysis is employed to coagulate the blood only 
the positive pole is applied by means of a flat plate of metal, 
covered with chamois leather well wetted with brine, and bound 
on to the neck or limb, while a needle attached to the negative 
pole is introduced into the nevus. From three to eight cells are 
sufficient for coagulation, but many introductions of the needle 
are required. Some prefer the positive pole, as its coagulating 
effect is greater. The needle must then be of gold or platinum, 
as steel needles leave a black mark. Where actual direct de- 
struction is desired, from fourteen to twenty cells are necessary. 
The needle should be passed in several directions below the 
base of the tumor, and it should be covered with gutta-percha 
or shellac at the upper part, where it is in contact with the skin, 
to prevent ulceration. Some advocate introducing both poles 
into the tumor, but this is necessary only for large nevi, and 
then Lewis Jones' instrument is useful. Five needles, alter- 
nately positive and negative, are fixed in one handle in a straight 
line, no wet pad is required. The proceeding is very painful 
with strong currents, and with weaker ones, many repetitions of 
the process are generally necessary. In any case, an anesthetic 
would be required, except for adults. 

Superficial nevi of moderate size are often very conveniently 
attacked by the strongest nitric acid or the acid nitrate of mer- 
cury. This last, if carefully used, leaves a thin white cicatrix. 
Richardson strongly advocated sodium ethylate to be painted on 
to " destroy nevi painlessly." I regret to say that it has not 
done all that is claimed for it in my hands. It was very painful, 
required many applications, suppuration was produced, and al- 
though it eventually destroyed the growth, the result was no 
better than nitric acid, and the process was more prolonged. 
The ethylate must be freshly and carefully made, great care 
must be exercised to keep the part quite dry, and the crust 
should be allowed to loosen spontaneously. Another very 
good plan for superficial nevi is the " Marshall Hall " method. 
A cataract needle is introduced close to the edge of the growth, 
and is pushed towards the opposite side; the needle is then 
nearly withdrawn, and pushed across again about one-sixteenth 
of an inch from the first one, and so on in radiating lines until 



966 DISEASES OF THE SKIN. 

the whole is traversed; cicatrization sets in gradually, and 
spreads over the whole growth, a few cases only requiring a 
second operation after some months. 

For more projecting nevi, my colleague, R. W. Parker, 
strongly recommended excision, and Lister has removed very 
large nevi by this method. Others prefer the ligature, as a rule, 
for nevi of large size. A large nevus needle is passed under the 
growth, and the tumor somewhat raised; another, armed with 
whipcord attached to it by a piece of silk, is passed under this. 
The armed needle is then withdrawn, and the cord drawn 
through with the silk; the other needle is now threaded, and 
the cord drawn through as it is withdrawn. The looped ends 
are now cut, and the cord of one pair tied tightly with the ad- 
jacent cord of another pair, so as to divide the growth into 
quarters. The skin must be divided by a scalpel, to allow the 
ligature to sink into the groove thus made, as the strangulation 
is rendered more complete and less painful. Other methods are 
described in surgical works. Some recommend puncturing in 
several places with the Paquelin or the galvano-cautery, and 
Hutchinson has used the Paquelin most successfully for very 
large nevi. Coates of Salisbury claims that filling the tumor 
by injecting tr. iodi into its substance is efficacious, and free 
from the dangers of perchlorid of iron. On the whole, for most 
superficial nevi I think best of electrolysis or the application of 
the fuming acid nitrate of mercury; for those more projecting, 
where the position and size permit, Parker's plan of excision, 
now that primary union can be insured, gives the best cosmetic 
result, as a linear scar only results. Where expense is no ob- 
ject, and the repetition of the operation is not contra-indicated, 
electrolysis may be first employed, by which the vessels are oc- 
cluded, but a small fibrous lump is left, which may be excised 
with a smaller incision than would have been required if cut out 
at first. If the position or size render excision unsuitable, either 
ligature or the galvano-cautery would probably be the best 
procedure. 

No doubt, if Coates' iodin injection does all he claims for it, 
it would be very valuable, but I have no personal experience 
of it. Most of the methods would be advantageous under par- 
ticular circumstances, of which the operator must form his own 
judgment, from what has been said. 



TALANGIECTASIS. 967 



TELANGIECTASIS. 

Deriv. — reXoi, the end; ayysiov, a vessel; and SuTaffiS, 
extension. 

Definition. — Acquired vascular dilatations. 

Symptoms. — Telangiectasis differs mainly from nsevus vas- 
cularis in its not being congenital. At the same time also, it is 
more often an enlargement of pre-existing vessels than a crea- 
tion of new ones, and clinically resembles the slighter forms of 
nevus. 

One of the most common forms is that which the older 
authors termed naevus araneus, or spider nevus. It consists 
of a central red, raised dot, from which fine lines radiate, with 
occasionally cross-lines connecting the radiations, the whole 
forming a stellate patch about one-eighth of an inch in diam- 
eter. The prominence is an aneurismal loop of an arteriole. 
The radiating lines are the dilated venous radicles. The lesions 
are, as a rule, solitary or few in number, occurring chiefly on 
the cheeks near the eyelids and the bridge of the nose. I have, 
however, seen them in enormous * numbers all over the face, 
below the forehead, and on the back of the forearms and hands 
in a girl of seven, in whom they commenced when five years old. 
Fresh dilatations were still appearing even at the age of four- 
teen; they gave a curious mottled look to the affected parts. 
Most of these differed slightly from the above description, 
there being no central projection, merely fine red lines, branch- 
ing out quite irregularly from mere dots to an eighth of an 
inch across. I have met with a similar case in a girl of ten, 
principally occupying the region between horizontal lines drawn 
across the eyebrows and the end of the nose; but there were 
signs of fresh ones on the lower part of the face and forearms. 

In another case, that of a man, they were almost confined to 
the right side of the face, where they were in great numbers. 
These lesions, singly or in small numbers, are sometimes seen 

* Author's Atlas, Plate LXX1., Fig. 1. A still more general distribution 
is recorded by Mandelbaum of Odessa, Viertelj . f. Derm. u. Syph., vol. 
ix. (1882), p. 213. They were in a continuous network on the face, where 
the disease had been longest, but had begun as spots and papules, and 
were after nine years in that condition on the trunk and limbs. 



9 68 DISEASES OF THE SKIN. 

on the neck and chest, and other parts; they are most common 
in women and children with delicate skin, occasionally follow 
a slight injury, and have also been seen in a diffuse form after 
lightning strokes,* but, as a rule, are apparently spontaneous. 
Stellate telangiectases are part of the symptomatology of xero- 
dermia pigmentosa. Another form, seen chiefly in the degen- 
erated skins of elderly, but sometimes in younger persons, con- 
sists of slightly convex or flat, hemp-seed-sized spots, raised a 
little above the surface, of a uniform bright crimson, or, occa- 
sionally, of purplish hue, and looking like a blood extravasation,, 
showing no indication of their structure to the naked eye, but 
really consisting of a tuft of dilated capillaries. They are chiefly 
seen on the upper. part of the trunk, neck, and face, and were 
called naevus sanguineus, but the term " nevus " is a misnomer 
for non-congenital growths. 

Brocq f records a case of a woman of fifty-nine, in whom 
there were numerous telangiectatic plaques, not raised above 
the surface, on the lower extremities from one-eighth to half an 
inch in diameter. There was a wafer-like scale over the plaque 
and slight scarring in places where there had been more or less 
involution. 

In Ullmann's and Kopp's cases there were veritable angi- 
omata. In Ullmann's case there were nodules from a millet 
seed to a pea on the face of a woman of forty which could be 
emptied on pressure. In Kopp's case the nodules were not so 
large, and on the scrotum, genital region, and flexor aspect of 
the limbs. This last case appears to resemble Fordyce's case of 
angiokeratoma of the scrotum (see p. 614). 

The scars of Rontgen ray burns frequently display a close 
network of dilated vessels, and in two cases I have seen the 
same condition after long or repeated exposures without any 
breach of surface, and therefore no marked scarring, although 
there was some atrophic change in the skin. Telangiectatic scar- 

*See a case by G. Boner of Duns, reported in the Lancet, with woodcut 
of telangiectases on the arm only. 

\ [our. des Maladies Cutane'es, vol. ix. (1897), p. 97. The case was 
shown to the French Dermatological Society. He gives references to 
seven other cases resembling his own more or less. Ullmann, Archiv f. 
Derm. u. Syph., vol. xxxv. (1896), p. 195 and photo. Kopp, toe. cit., vol. 
xxxviii. (1897), p. 69. Abs. Brit. Jour. Der?n., vol. ix. (1897), p. 416. 
Abs. of Ullmann's Amiales de Derm , vol. viii. (1897), p. 141. 



TALANGIECTASIS. 969 

ring is, therefore, almost characteristic of Rontgen ray 
burns. 

The only other condition that concerns the dermatologist is 
the dilatation of venules of the face, called Rosacea, or chronic 
venous congestion of the face, which is, as a rule, mixed up with 
acne, and is described with acne rosacea, but it may occur apart 
from that condition, as in people much exposed to the weather, 
such as seamen, coachmen, etc. It may occasionally occur 
after a single exposure to the sun, but, as a rule, it is the result 
of causes which lead to chronic congestion of the face or ob- 
struction in the venous flow, whether central, as in weakly- 
acting hearts, or peripheral, as in chronic chilling of the surface. 
This I have seen in a lady who was devoted to motoring. The 
result is that the venous radicles become dilated and visible 
on the surface, especially on the nose, cheeks, and chin. The 
further results are described in the third stage of acne 
rosacea. 

Schweninger has drawn attention to the occurrence of 
arborescent dilatations of the cutaneous vessels along the rib 
border of one or both sides in obese men with a feeble circula- 
tion; it also occurs when there is obstruction to the intra- 
thoracic venous flow, and Blake calls it the athlete's girdle. 
Similar arborescent dilatations often occur at the border line 
in general and localized sclerodermia. 

Treatment. — By far the best treatment for the dilated vessels 
is occlusion by electrolysis, as described for removing super- 
fluous hairs. In the so-called naevus araneus the point of the 
negative pole needle is inserted into the central projection, and 
a current of about three cells transmitted. Slight frothing 
ensues; the skin just round the needle blanches, while beyond 
it is reddened. The needle must only be kept in three or four 
seconds, or there will be a mark. The dilated venous radicles 
may be occluded in a similar way, as described under acne 
rosacea. 



97© DISEASES OF THE SKIN. 

ANGIOMA SERPIGINOSUM. 

Synonyms. — Infective angioma * ; Nsevus lupus. 

Definition. — A disease in which minute vascular points are 
formed in rings or other groups, which spread at the borders, 
while fresh points are continually developing beyond them. 

This disease is very rare, and was first described by Hutchin- 
son. f Other cases have been met with by Jamieson, Lassar, 
Waren Tay, J. C. White, Leslie Roberts, Majocchi, and myself. 

This disease consists of minute, bright red, vascular points 
imbedded in the skin, " like grains of cayenne pepper." These 
are formed into small groups, which spread peripherally, clear- 
ing in the center, and thus forming rings not exceeding half an 
inch or so across, but in the border the vascular dot character 
of the components of the ring is always preserved. Fresh 
points are continually developing a little beyond the patches 
(" infective satellites," as Hutchinson calls them), and thus the 
process is continually repeated, and, the rings meeting, large 
areas of disease with gyrate borders are produced. Scattered 

* I have ventured to give another descriptive adjective than that of 
Hutchinson, since his word " infective " would have to be rendered " Con- 
tagiosum," and thus convey a false notion, which he himself did not 
intend, the word " infective " here only indicating the infective in- 
fluence on adjacent tissues. 

f Literature. — The first four cases are described in Hutchinson's 
Archives of Surgery. In describing Waren Tay's case, he gives refer- 
ences to the rest. Vol. iii. (1891), p. 166, illustrated (Plate IX.). Compare 
with Plates XIII. and XIV., which he calls lupus marginatus. These 
cases are republished in his smaller Atlas with the same numbers. J. C. 
White, Amer. Jour. Cut. Dis., vol. xii. (1894), p. 505, with illustrations of 
microscopical appearances. Leslie Roberts, Brit. Jour. Derm., vol. ix. 
(1897), p. 180, with histology. Francis' case, " A Rare Form of Angioma 
Serpiginosum," Internat. Atlas, Plate XXXIV., appears to be a growing 
capillary nevus of the "port wine" character. David Walsh's case, 
Hutchinson's Arch., vol. viii. (1897), Plate 143, was in arborescent lines, 
it spread down one arm and all over the body, leaving slight scarring, 
Brit. Jour. Derm., vol. x. (1898), p. 18. It was a remarkable serpiginous 
angioma, but quite different from the text cases. Morgan Dockrell, Med. 
Soc. Trans., vol. xxi. (1898), p. 654, records a case under this title in 
which the telangiectatic vessels began at three months old, persisted 
until he was sixteen years, and then disappeared, leaving scars; but the 
description is insufficient for exact identification. 



ANGIOMA SERPIGINOSUM. 



971 



*' cayenne pepper " dots, and lines of them, are seen beyond 
the main patches, and the skin between the rings is generally 
pinkish in hue; in Tay's case the ringed arrangement was but 
slightly indicated, and there was no definite grouping. The dots 
vary from the diameter of an ordinary pin's head to some so 
small as only to be visible with a lens. Most of them are 
bright, and pale on pressure, but the larger-sized ones are 
purplish in hue and often unaltered by pressure. In three out 
of the first four cases scarring was certainly absent, and 
Hutchinson was not sure about it in the fourth case. This case 
began at the back of the arm, and spread up and down the limb 
to the shoulder and to below the elbow. Jamieson's case began 
on the front of the right forearm, and spread over the front and 
back of the arm and forearm, up to the deltoid, and down to 
the radial side of the wrist and back of the hand, to the root of 
the thumb and forefinger. There were also several groups along 
the inferior margin of the fifth rib on the right side, from on£ 
inch inside the nipple to the right border of the sternum. 
Lassar's case began on both cheeks and increased to the size 
of a florin; a few groups came on the ears, and later, on the 
right upper limb, and extended from the humerus to the back 
of the right hand in eight weeks. Tay's case began on the right 
calf, and spread nearly all over the leg, and another patch 
formed on the front of the thigh. The left limb was less af- 
fected. The disease tends to spread but very slowly, as a rule, 
though Lassar's case, as far as the arm was concerned, was a 
marked exception. There are periods of comparative quiescence 
and activity. 

In Leslie Roberts' case, a girl, set. fifteen, it began on the leg 
when four years old, and spread from ankle to buttock in count- 
less vascular puncta in circular and crescentic clusters. She was 
born with a nevus on her lip. 

In White's case there was a purplish-red mark at birth below 
the right scapula; it increased slightly, but it was not until he 
was four years old that " satellites " appeared. It formed when 
the boy was seen, set. twelve years, a belt three inches wide, 
extending for six inches from the right scapula towards the 
nipple. There were about two dozen lesions from a pin's head 
to two-inch circles. There was no scarring, only purplish dis- 
coloration inside the circles. 



972 



DISEASES OF THE SKIN. 



In my own case, a pregnant woman of twenty-one, the face 
only was affected. It began two months before I saw her, on 
the right cheek, then appeared on the forehead, where there 
were three circles about three-quarters of an inch in diameter,, 
made up of punctiform vascular dots. There were two on the 
left cheek, two over the lower jaw, and two small groups on 
the right cheek. There was no scarring even where the original 
patch on the right side had faded, except a few puncta, and left 
the skin white. 

Etiology. — Three out of the first four developed under two 
years of age, and all these three were girls. Jamieson's case 
developed in a boy, set. fifteen years, after gymnastic exercises; 
Hutchinson's developed from a small port-wine mark soon after 
birth; Lassar's case after convulsions connected with dentition; 
and Tay's case without apparent cause when two years old. 
White's case started from a nevus. In my own case there was 
mitral disease. Of the six cases, therefore, three started where 
there was pre-existing nevus and three under circumstances sug- 
gestive of vascular strain. 

Pathology. — Its pathology is unknown. Hutchinson consid- 
ers it a sort of lupus and allied to lymphangiectodes or lymphatic 
lupus, as he terms it, because both begin in early life, spread 
at the edge, and have satellites, and any disease with these 
phenomena comes under his definition of the lupus family, but 
these views are not generally accepted as regards lupus in gen- 
eral. Lassar, however, described his case as a form of lupus 
erythematosus. 

Anatomy. — Jamieson's case was examined by Edington, who found the 
epidermis normal, except that the interpapillary processes of the rete went 
deep into the corium. The vascular loops at the apices of the papillte 
were dilated into wide spaces, some still with blood in them. Anatomic- 
ally, he considered that the condition was that of a superficial nevus. 
Councilman and Bowen, who examined White's case, concluded that there 
was first a growth of the endothelium and perithelium of the vessels of the 
corium, and along with this a formation of new vessels both of them; and 
Darier, who also examined sections, regarded it as an angio-sarcoma of 
special type. Majocchi * found the ectasic capillaries round the follicular 
orifices. Leslie Roberts only found spaces formed by dilated vessels. 

* I have only seen a short abstract of this case in the Monatsh. 
Majocchi called it, " Telangiectasis follicularisannulata," " an undescribed 
dermatosis." 



LYMPH ANGIECTASIS AND LYMPHANGIOMATA. 973 

Diagnosis. — This can scarcely offer any difficulty. The com- 
mencement some time after birth at once shows it is no mere 
birthmark, and its punctiform character in groups, rings, lines, 
or single dots, and tendency to spread in an annular manner, 
with the continual formation of fresh foci beyond the main 
patch, stamp it as something peculiar. The stellate telangi- 
ectases, which occur at all ages and may be very numerous, are 
distinguished not only by their branched character, but by the 
absence of any serpiginous tendency. Though compared by 
Hutchinson to lymphangiectodes, that only refers to the mode 
of development, as their physical characters are quite different, 
except that some telangiectases are often present along with the 
vesicles in that condition. 

Treatment. — The treatment hitherto tried has been unsuccess- 
ful, the disease spreading in spite of the measures adopted. I 
should be inclined to try electrolysis along the border of the 
affected area, and so produce occlusion of as many vessels as 
possible along the spreading edge and in the outlying puncta. 

LYMPHANGIECTASIS AND LYMPHANGIOMATA.* 

These two conditions, as Unna has pointed out, frequently 
merge into each other, for the latter is always accompanied by 
the former, and even in lymphangiectasis there is endothelial 
proliferation. Lymphangioma, Unna considers, is comparable 
to varicosity of the blood-vessels rather than to true he- 
mangioma. 

There are two superficial forms of dermatological interest, 
lymphangiectasis, the lymphangioma superficiale of Unna\ in 
which pale elastic elevations appear on the skin, which may 
become so superficial as to be bluish and translucent, or actu- 
ally vesicular and transparent; if these vesicles or nodules are 
punctured or ruptured, lymph flows from them in large quanti- 

* Unna's " Histopathology," p. 919-933. Amer. Jour. Ctit. and Gen.- 
Ur. Dz's., vol. x. (1892), p. 213, illustrated. Vol. xiii. (1894), p. 137, for 
Elliot's case, and vol. xvi. (1898), p. 67, for White's case. Priv. Notes, L., 
p. i4r. A gentleman, set. forty-two, thirteen years before had a sudden 
attack of lymphangitis in the forearm with great swelling which never 
quite subsided, and during the last nine months had had minute closely 
aggregated vesicles at the wrist, which never went away, and were fuller 
in hot weather. 



974 DISEASES OF THE SKIN. 

ties, and the discharge may go on for hours. This condition is 
really the only visible change in the skin, and Heuss', Epstein's, 
G. J. Elliot's, White's, and Pringle's cases, and one of my own, 
are examples, and many more might be cited. It is due to a 
superficial erysipelatous, or other inflammation, or the conse- 
quence of a traumatism. More frequently the condition is asso- 
ciated with lipomata or elephantiasis, either congenital, as in 
elephantiasis congenita lymphangiectodes, or acquired, either in 
the tropical or home form of elephantiasis. 

The second superficial form is described here under the title 
of lymphangiectodes, because it was the original name given 
by Tilbury Fox, and still represents as much of the pathology 
as lymphangioma does. Unna's lymphangioma of the hypo- 
derm rests on Pospelow's case of so-called lymphangioma 
tuberosum multiplex, which will be further alluded to in the 
description of the disease originally described by Kaposi under 
that title, and adhered to here, as its pathology is still a matter 
of discussion, though the tendency is not to admit that it is a 
lymphangioma. 

Cystic lymphangioma is the hygroma of surgeons, and does 
not concern the dermatologists; Dale James' case* was an in- 
teresting variety. 

For further discussions on lymphangiomata, the papers of 
Francis and Leslie Roberts f may be read. 

LYMPHANGIECTODES4 
Deriv. — \viiq>ayyia y lymph vessels; EMTaffiS, dilatation. 
Synonyms. — Lymphangioma circumscriptum (M. Morris); Lu- 
pus lymphaticus (Hutchinson); Lymphangioma capillare 
varicosum (Torok); Lymphangioma cavernosum (Besnier); 
Angiome cystique (De Smet and Bock). 

Definition. — A localized disease consisting of closely crowded, 
deep-seated vesicles supposed to be connected with the 
lymphatics. 

This is a rare disease, which was first described by English 
authors. Tilbury Fox first, then Hutchinson, described cases, 

*Read before Sheffield Med. Chir. Soc., Lancet, February 28, 1891. 
f Brit. Jour, of Derm., vol. v. (1893). pp. 4, 65, and 364. 
% Literature.— -T. and C Fox, "Lymphangiectodes," Path. Trans., 
vol. xxx. (1879), p. 470, with histology — a complicated case. Hoggan also 



L I W1PHAXGIECT0DES. 9 7 5 

but of late so many have been published that it is no longer 
necessary to particularize them. Eight cases have occurred in 
my own practice. 

Tilbury Fox's and Besnier-Vidal's cases were complicated 
with venous nevus; Kobner's was described as a case of 
cavernous angioma, lymphangioma, and neuro-fibroma; and in 
Dale James' case also, the vesicles were seated on a fibro- 
cavernous structure; the uncomplicated cases resemble each 
other very closely. 

Symptoms. — The disease consists of minute, deep-seated vesi- 
cles, like frog-spawn. They are closely crowded together in 
irregularly outlined groups of from one-third to three-quarters 
of an inch in size, and these again are arranged irregularly with 
healthy skin between them, or with only a few scattered vesicles 
on it. They are usually in a single patch from one to three 
inches in diameter, or at least confined to one region, of which 
the following areas are on record: the face, lip, neck, deltoid 
and scapular regions, the axillae, the arm, leg, thigh, buttock, 
trunk, groin, and vulva. In Corbett's case it formed a half-inch 
band from the middle of the thigh behind to the tendo Achillis, 
and thence under the external malleolus it broadened and ended 
on the middle and inner margin of the foot, the majority have 
occurred on the left side. The mucous membranes may be at- 
tacked, the tongue * most frequently; in Brocq's the tongue and 
soft palate; in Schmidt's the upper, and in my own the lower 

gives histology of this case, Jour, of Anat07ny and Physiology, vol. xviii. 
(1834), p. 322. Hutchinson, "Lupus Lymphaticus," two cases, Path. 
Trans., vol. xxxi. (1880), p. 342, with two excellent colored plates 
and very good clinical account with, histology by Sangster — these two 
and another are reproduced in Plates XV. and XVI., vol. i., Archives of 
Surgery. Hutchinson, Jr., " Histology," Path. Trans., vol. xxxv. (1885), 
p. 467, with plate. Kobner, Berlin Med. Soc, 1883; reported fully in 
Ann. de Derm, et de Syph., vol. v. (1885), p. 293. Morris' case, Plate I., 
International Atlas. My own Atlas, Plate LIXXV., four cases. A. G. 
Francis, Brit. Jour. Derm., vol. v. (1893), pp. 4, 65, and 364, several new 
cases and good resume of old. Brocq and Bernard, Anjiales de Derm, et 
de Syph., vol. ix. (1898), p. 305, gives nearly all the references and critical 
review. Kaposi, Besnier-Doyon, vol. ii. p. 378, notes by translators. H. 
Schnabel, Archiv f. Derm., vol. lxi. (1901), p. 177, histological plates and 
many references. 

*Butlin, "Diseases of the Tongue," 1885, Plate VII., colored, reported 
as a degenerated nevus. Hutchinson's smaller Atlas, Plate LXXXVI. 
Brocq, loc. cit., gives references to seven cases. 



976 DISEASES OF THE SKIN. 

lip,* was affected in association with lupus vulgaris of the face; 
Doutrelepont has met with a similar combination; in Walsh's, 
the papebral conjunctiva; in Leroux's, the buccal mucous mem- 
brane; in Heuss', the in- as well as the outside of the labia 
vulvae. Probably no part of the skin or mucous membrane is 
absolutely exempt, but the most common positions are the side 
of the neck, the scapulae, axillae, and sides of the trunk, on the 
skin and the dorsum of the tongue, on mucous membranes. 

The vesicles are not of the ordinary kind, being deep-seated, 
with thick walls, and some of them are almost warty-looking. 
The majority are about the size of a small pin's head, but they 
vary from the smallest recognizable up to a large hemp seed. 
They are either perfectly colorless, or have a straw or pinkish 
tinge, and if pricked, emit a clear, colorless fluid of alkaline 
reaction, containing a few lymph corpuscles. Some have vas- 
cular striae or tufts over them, others have red dots, others 
again evidently contain extravasated blood, and even external 
hemorrhage may occur in places like the axilla, the result usu- 
ally of friction or other trifling injury. In one of Hutchinson's 
unpublished cases nearly all the vesicles had vascular tufts 
obscuring the vesicular character. In one of my cases these 
vessels were conspicuous during the development of fresh vesi- 
cles, and disappeared subsequently. Verrucose projections with 
horny concretions are sometimes present. There are no inflam- 
matory or subjective symptoms as part of the disease, but J. C. 
White's case had had frequent attacks of dermatitis and 
Hutchinson also speaks of their liability to erysipelatoid inflam- 
mation. The disease is extremely chronic in its course, lasting 
for an indefinite number of years, if not interfered with, spread- 
ing slowly at the periphery by the formation of fresh groups of 
vesicles, and with great tendency to recur after partial or ap- 
parently complete removal. In the second of my cases, aet. 
thirteen, the disease had only been noticed a month, and ap- 
peared on or near some scars produced by the removal during 
infancy of a congenital tumor, which the mother said was not 
like the present disease, but there must have been several 
growths, judging by the scars over the left ribs. 

Etiology. — Sex appears to have no influence. Nearly all have 
begun in childhood, a few in early infancy; one of mine began 
* Atlas, Plate LXXIV., Fig. 4. 



LYMPHANGIECTODES. 977 

when six months old, and one or two have been possibly con- 
genially present, and all are probably of congenital origin. 
Several have been associated with venous nevus, and Besnier 
attaches great etiological and pathological importance to this. 
Pathology. — All but Besnier and De Smet and Bock regard it 
as of lymphatic origin, and that the main features are over- 
growth and dilatation of the lymphatic vessels; of congenital 
origin and comparable to blood vascular nevi; but when one 
comes to details, the variety of nomenclature indicates the 
variety of opinion. De Smet and Bock consider that the vesi- 
cles are serous cysts derived from the arterial capillaries of the 
papillary body. Torok, while convinced that the change is 
mainly lymphatic, admits that the blood-vessels take part in the 
process, a view confirmed by its occasional association with 
blood-vessel nevi. The varying number of dilated blood-vessels 
at different periods perhaps explains some of the discrepancy. 
Brocq * considers it to be a neoplasia of the lymphatic vessels. 
All are now agreed that there is overgrowth as well as dilata- 
tion. Hutchinson's view that it is a kind of lupus is not ac- 
cepted by anyone except his son, but he uses the term in a 
special clinical sense, rather than to imply that it has any rela- 
tionship to lupus vulgaris. 

Anatomy. — The histology has been investigated by T. and C. Fox, 
Sangster, Hutchinson, Jr., Torok, Schmidt, De Smet and Bock, Jacquet, 
Heuss, Francis, Roberts, Freudweiler, Brocq, Gilchrist, etc. All are 
agreed in the presence of cysts of various sizes, chiefly in the papillary, 
but also in the deep part of the cutis, and sometimes deeper still. For 
further details see the references. 

Diagnosis. — Its commencement in early childhood, its slow 
but continuous progression, the congeries of small, thick-walled, 
warty-looking vesicles in the cutis, their straw color, with vas- 
cular striae, and their limitation to one region, are the most 
distinguishing features, which, once seen, could scarcely be mis- 
taken for those of any other affection, except cases of lymph- 
angiectasis like those of Epstein and Elliot, f from which it 

* Brocq, loc. cit., discusses in detail the pros and cons of the blood or 
lymph vessel origin of the disease, and is a good contribution to the 
pathology of the affection. 

fCase of lymphangioma, Amer. Jour. Cut. and Gen.-Ur. Dis. vol. x., 
p. 213, illustrated, also G. T. Elliot, Amer. Jotir. Cut. Dis., vol. xii. (1S94), 
p. 137. Fox and Hoggan, loc. cit. J. C. and C. J. White, Amer. Jour. 
62 



978 DISEASES OF THE SKIN. 

might be distinguished by the continued lymphorrhagia when a 
vesicle of the latter disease is punctured, and probably also that 
such cases may not be restricted to one region. 

Prognosis. — There are too few cases on record to speak de- 
cisively; as far as we know, spontaneous disappearance is not 
to be looked for, and even after apparent destruction it has 
returned. 

Treatment. — Destruction by caustic or excision has been 
practiced, but not always with success, as recurrence often took 
place near the cicatrix. In one of my own case? the greater 
part had been destroyed by caustics a year before I saw it, but 
many fresh groups had appeared on and round the scars of 
previous operations. I tried electrolysis; each vesicle was 
pierced by the needle attached to the negative pole, and eight 
to ten cells were employed; the result was satisfactory for some 
time, but there was partial recurrence three years later. Still, 
unless excision could be accomplished going widely beyond the 
visible disease, electrolysis is probably the best plan, if it is 
interfered with at all. 



LYMPHANGIOMA TUBEROSUM MULTIPLEX.* 

Synonyms. — Eruptive Hydradenoma (Jacquet-Darier) ; Adenoid 
epithelioma of the sweat glands (ditto); Syringo-cysta- 
denoma (Torok) ; Syringadenoma or syringoma (Unna) ; 
Cystic eruptive epithelial celluloma (Quinquaud); Benign 
cystic epithelioma (Jacquet); Benign epithelioma with col- 
loid degeneration (Philippson) ; Benign epithelial cysta- 
denoma and cystic epithelial nevi (Besnier); Endothelioma 
tuberosum multiplex colloides (Kromayer); Syringo- 
cystoma (Neumann); Hemangio-endothelioma tuberosum 
multiplex (Jarisch). 

Kaposi was the first to describe a case of this rare disease 
from Hebra's clinic, and the name he gave it stands, therefore, 
at the head of this article on the score of priority, but not as 

Cut. Dis., vol. xvi. (1898), p. 67, and many other such cases are scattered 
through medical literature. 

* Literature, — Hebra's Atlas, Lief, x., Tafel 6. Hebra, vol. iii. p. 387. 
Syd. Soc. Trans. " Hydradenomes eruptifs," Jacquet et Darier, Annates 
de Derm, et de Syfth. (1887), p. 317. Piece No. 1175 du Musee de 1'HopitaL 



LYMPHANGIOMA TUBEROSUM MULTIPLEX. g79 

representing the true nature of the growths, as it is worse than 
useless to change it until more general agreement is obtained 
as to the pathology of the affection, than the farrago of syno- 
nyms indicates to be now the case. 

Including one of my own, about a score of cases are known 
besides those of Pospelow, Van Harlingen, and Leslie Roberts, 
which will be considered separately. 

In the majority of the cases the lesions occupy the front and 
sides of the trunk, generally appearing under the clavicle, 
where they are always most abundant, and extending more or 
less downwards, reaching in the Hebra-Kaposi case all over 
the front of the body; if it extends upwards, the neck, and per- 
haps even the lower part of the face, is reached, while in Quin- 
quaud's and Philippson's cases the forehead and orbits were 
affected and the lower part of the face was free. In Jarisch's 
case the orbits only were involved. Posteriorly it seldom ex- 
tends further than from the hair line to the nucha; both seg- 
ments of the upper limbs, and the upper segments of the lower 
limbs, have been sparsely involved. 

The lesions are discrete, crowded in some parts without 
definite grouping, but with a slight tendency to an arrangement 

St. Louis (1886). " Syringo-Cystadenom," L. Torok, Monatshefte f. 
prakt. Derm., vol. viii. (1889), p. 116. "Die Beziehtmgen des Kolloid 
Milium (E. Wagner) und des Hydradenom (Darier-Jacquet) zueinander," 
L. Philippson, Monatshefte f. prakt. Derm., vol. xi. (1890), No. 1, and 
English Trans., Brit. Jour. Derm., vol. iii. (1891), p. 35. "Cellulome 
epithelial eruptif," Quinquaud, Comptes Rendus (Paris, 1890), p. 412, 
Congres Int. de Derm. (Paris, 1889). " Epitheliome kystique benin dela 
peau," Jacquet, loc. cit., p. 416. " Lymphangioma Tuberosum Multiplex," 
Lesser and Beneke, Virchow's Arch., 1891, Keft 1. " Zur Lehre von den 
Haut-geschwulsten (Hemangio-endothelioma)," Jarisch, Arch.f. Derm, 
u. Syph., vol. xxviii. (1894), p. 164. " Endothelioma Tuberosum Colloides," 
Kromayer, Virchow's Arch., Bd. cxxxix. , p. 282. " Epitheliomes Kys- 
tiques benins," Brocq, Annates de Derm, et de Syph., vol. viii. (1887), p. 
289. " Hemangio-Endothelioma Tuberosum Multiplex," by Hugo Gutti, 
of Breslau; reprint Braumiiller, 1900, from Kapos' "Festschrift." 
"Hemangio-Endothelioma Tuberosum Multiplex," and " Hemangio- 
Sarcoma Cutis," M. Wolters, Archiv f. Derm, tt Syph., September, 1900, 
p. 269. Abs. in Brit. Jour. Der?n., vol. xiii. (1901), p. 75. Five cases by 
A. Gossman in October and November Nos. of Archiv (1901), p. 177. He 
calls them Nsevi Cyst-Epitheliomatosi Disseminati. Abs. Brit. Jour. 
Derm., vol. xiv. (1902), p. 191. A new case by the author, Clin. Soc. 
Trans., vol. xxxii., 1899. Colored plate and references to date. 



9 8o DISEASES OF THE SKIN. 

in oblique lines from the clavicles to the sternum, apparently 
following Langer's lines of cleavage. Individually they are 
convex, roundish, or oval, rather firm nodules, imbedded in the 
skin, not very well defined, and only slightly raised above the 
surface. They range in size from a pin's head to a small pea, 
or occasionally as large as a bean. In color, they are pink, 
brownish or reddish-yellow, slightly paler on pressure, while 
the small ones are often the color of the normal skin. The sur- 
face is smooth to the naked eye, but with a lens, fine corruga- 
tions most marked at the border, can be seen (on the larger 
growths). Telangiectases on them are exceptional. On many 
of them one or more yellowish or translucent milia can be 
found, or they may occur separately. Sensory symptoms are 
quite absent as a rule, but Kaposi spoke of them as being 
slightly painful. 

They generally commence in childhood or adolescence, and 
slowly increase in numbers, and still more gradually in size, 
and show no tendency to involution. A case of Hallopeau's, 
very unlike the rest, developed true epithelioma; the primary 
lesions were yellow rounded firm nodules on the eyelids of a 
man, and dated from infancy. 

Anatomically, in the center of the derma are cysts of various 
size, lined with flat nucleated epithelium, and from most of these 
proceed straight or winding ductlike cylinders of epithelial cells, 
of about the same thickness as a sweat-gland duct. By the 
accumulation of epithelium, and subsequently hyaline degenera- 
tion, these pseudo-ducts may become dilated into cysts, some 
of which are isolated in the derma without any process belong- 
ing to them. 

When authors tried to read the pathogenetic meaning into 
these anatomical facts, difficulties began. Kaposi thought they 
were lymphangiomatous cysts, " Darier and Jacquet first 
thought that they were adenoid growths from the sweat 
glands, then that they were sweat-gland epitheliomas, Quin- 
quaud and Jacquet that they were benign cystic epitheliomas," 
Kromayer and Jarisch that they were endotheliomas derived 
from the blood-vessels; Gutti and Wolters also consider them 
to be hemangio-endotheliomata. Torok suggested that thev 
develop from embryonic positions of sweat glands in accord- 
ance with Cohnheim's theory, and this seems a feasible idea, 



LYMPHANGIOMA TUBEROSUM MULTIPLEX. 981 

and his name, syringocystadenoma, is the least clumsy and ob- 
jectionable of the names proposed. As, however, his idea has 
not been proved, and the majority of observers derive them 
from the blood-vessel endotheliomas, it is better to retain for 
the present the original designation, and at least we shall then 
know on what peg to hang these rare cases as they arise. The 
milium so often present is also, no doubt, of embryonic origin, 
as Robinson first showed was often the case with these white 
fatty bodies. 

Diagnosis. — The diagnosis should not be difficult, as a rule; 
their slow development generally dating from the second dec- 
ade of life; their predominance on, and perhaps limitation to, 
the upper part of the front and sides of the chest; the color 
being from normal to reddish or yellowish-brown; their size 
from a pin's head to a pea; the arrangement in oblique rows; 
the firm consistence and neoplastic character, with absence of 
sensory symptoms — would be the most distinguishing features, 
and no other disease presents similar appearances, except 
epithelioma adenoides cysticum. The comparison between the 
two will be made under the latter affection, in which also the 
prognosis and treatment are identical, and will, therefore, not be 
discussed here. 

There remain Pospelow's * and Van Harlingen's f cases, 
which are reported as instances of lymphangioma tuberosum 
cutis, and a case related and identified by Leslie Roberts J as of 
the same character. 

No one can read these cases carefully without being struck by 
their resemblance to each other, and to some cases of fibroma; 
and since Van Harlingen now admits that his case was probably 
a fibroma, further discussion is unnecessary. 

*Pospelow. Viertelj. f. Derm. u. Syph., vol. vi. (1879), p. 521, 
■f-Van Harlingen, Amer. Derm. Soc. Trans., 1881, and "Manual of 
Diseases of the Skin," 2d ed., 1889, p. 299. 
^Leslie Roberts, Brit. Jour. Derm., vol. viii. (1896), p. 312. 



982 DISEASES OF THE SKIN. 

EPITHELIOMA ADENOIDES CYSTICUM (Brooke).* 

Synonyms. — Adenoma of sweat glands (Perry); Multiple benign 
cystic epithelioma (Fordyce); Hemangio-endothelioma tu- 
berosum multiplex (Jarisch); Acanthoma adenoides cysti- 
cum (Unna). 

This is an equally rare disease with lymphangioma tuberosum 
multiplex, with which it presents many resemblances and 
analogies, but as there are some important differences, they are 
kept apart, at all events for the present. 

The lesions are for the most part on the face, and include 
Perry's case, which may be taken as the type; the Brooke and 
Fordyce series, Balzer and Menetrier's case, and f a few others. 

In adopting Brooke's name, epithelioma, I have been guided 
by the fact that it is the one most widely accepted, but the 
generic term epithelioma is used in a wide, and in this instance 
benign sense, indicative of the supposed derivation of the 
growths from the epidermis. 

In Perry's case the lesions were limited to the face and scalp 
in closely aggregated groups about the center and sides of the 
forehead, the root of the nose and inner canthi, the cheek and 
upper lip close to the nose, and the lower lip, except as regards 
the forehead, having very nearly the distribution of a marked 
case of adenoma sebaceum, which it resembled, except that the 
lesions were white and had no telangiectases, but this latter 
feature was to a slight extent present in Fordyce's cases (a 
mother and daughter). In Philippson's first case the nodules 
were limited to the lower eyelids, the color of the normal skin, 
but translucent and only distinguished by the microscope from 
colloid milium. 

In Brooke's four cases (three in one family) the face was like 
Perry's case, but one, in addition, had them on the back of the 

* Literature. — Perry's case, International Atlas, Part III. Plate IX. — a 
good representation. Brooke, Brit. Jour. Derm., vol. iv. (1892), p. 269 — 
a good article and references to date, and four new cases. Fordyce, 
Amer. Jour. Cut. and Gen.-Ur. Dis., vol. x. (1892). Kromayer, Virch. 
Arch., vol. cxxxix. 

f Balzer and Menetrier, "Adenoid of the Sebaceous Glands of the 
Face and Scalp," Arch, de Physiol., 1885, P- 5i5» quoted in Unna's 
*' Histopathology," p. 1124. 



EPITHELIOMA ADENOIDES CYSTICUM. 983 

neck, the upper third of the back, and very marked in the inter- 
scapular region. In another there were more on the back than 
the front, and the scalp was much affected, but the hair grew on 
the lesions. The color was normal or with a slightly bluish- 
yellow tint. In Fordyce's cases some of the lesions were 
pearly and translucent, with some telangiectases, and the lesions 
were less crowded than in the other cases. 

It is probable that Jamieson's * and Rosenthal's f cases, de- 
scribed as adenoma sebaceum, were really instances of this dis- 
ease of the Perry type. In J. C. White's J case, a woman of 
forty-two, the lesions began on the face at the age of twenty- 
four. They were sparse then and numbered about fifty when 
White saw her, though they had continued to develop up to the 
age of forty-two. Some softened and were removed by caustics 
during the last ten years; three of them developed epithelioma. 
Bowen examined some of the lesions microscopically, and con- 
sidered that they were identical with those of Fordyce's cases, 
but there were obvious clinical differences. 

Wolters' § case was a woman of twenty, in whose right eye- 
brow was a yellowish-red-colored linseed-sized tumor, which 
had been present since birth. The diagnosis was made from the 
histology corresponding with Brooke's disease. 

Elsching|| at Vienna showed two sisters, set. twenty-six and 
twenty-nine, with numerous whitish-yellow flat pin's-head to 
lentil-sized neoplasms on the lower eyelids, which they from 
their histology considered as lympho-endotheliomata. 

Jarisch's case was a man, set. twenty-two, in whom the dis- 
ease began at the age of eight. There were several ulcerated 
and crusted plaques situated about the orbits, and one near the 
nose, which looked like rodent ulcers. There were a few nodules 
and yellowish milium on the eyelids. Microscopically, Jarisch 
said they resembled Brooke's cases, but with such clinical dif- 
ferences it would be better to suspend judgment. 

*Jamieson, Brit. Jour. Derm., vol. v. (1893), p. 138. 

f Rosenthal, Berlin Derm. Soc., reported in Annates de Derm, et de 
Syp/i.. vol. v. (1894), p. 1 151. 

%Amer. Jour. Cut. Dz's., vol. xii. (1894), p. 477. with good photograph. 

§ Wolters, Archiv f. Derm. u. Syph., April and May, 1901, pp. 89 
and 197. 

I Elsching reported Annates, vol. ix. (1S98). p. 1059. 



984 DISEASES OF THE SKIN. 

W. Pick's * was in a man of forty-three, with a few (9) scat- 
tered lesions on the forehead and orbits. 

Isadore Dyer's, f a man of fifty-five, in whom the disease began 
at eighteen on the left temple, and gradually increased on the 
face, neck, chest, and back, and were both grouped and scattered 
from a pin's head to a pea, and a few as large as half a nut; 
the newer ones were like white wax, the older violaceous. 

Etiologically the disease shows heredity and family prevalence 
in a large proportion of the cases. The female sex predominates 
so largely that male cases should be carefully scrutinized before 
they are accepted as being of the Perry type, especially as those 
reported by Jarisch, Pick, and Dyer present important clinical 
differences. 

Anatomy. — Brooke and Fordyce independently traced the growths from 
the epidermis epithelium, and consider them to be benign epitheliomata, 
while Jarisch and others have derived them from vascular or lymphatic 
endothelium, and would therefore class them as endotheliomata. Most 
subsequent observers, however, including Unna, who calls it an 
acanthoma, and Wolters, confirm Brooke and Fordyce. 

Pathologically there is a general agreement that they are of 
embryonic origin. 

Diagnosis. — These cases resemble either adenoma sebaceum 
when abundant, or sometimes colloid when limited to the orbits. 
The distribution and aggregation may be exactly like adenoma 
sebaceum, except on the forehead, where the growths are 
sparse in adenoma sebaceum, while in the other they are 
closely grouped for the most part; the color, chiefly due to 
telangiectases, is usually bright red in adenoma, while in epi- 
thelioma adenoides the growths are pale and even white, and if 
there are telangiectases, they are not nearly so numerous and 
do not give the ruddy coloration of adenoma. When they are 
on the orbit they may be yellowish and semi-transparent, and 
then are like colloid. In a few cases, chiefly when the growths 
are sparse, the microscope would have to decide the question. 
The following comparison may be made with lymphangioma 
tuberosum. 

*In vol. lviii. (1901), p. 201, W. Pick records as adeno-epithelioma what 
he claims to be another case. He mixes up cases of adenoma sebaceum, 
colloid, etc., in his references. 

f Isadore Dyer, New Orleans Med. and Surg. Jour ., March, 1898, p. 530. 



EPITHELIOMA ADENOIDES CYSTICUM. 985 

Lymphangioma Tuberosum Epithelioma Adenoides 

Multiplex. Cysticum. 

Mainly on the trunk, discrete and Mainly on the face, discrete but 

not grouped. Bilateral, but not very closely grouped. Closely sym- 
symmetrical. Distinctly colored, metrical. Almost or quite pearly 
except quite at the commencement. white throughout, or a faint bluish 
Scalp unaffected. or yellowish tinge. Scalp several 

times affected with large and nume- 
rous lesions. 

Males and females equal. Females largely predominate. 

Not hereditary. Most of them hereditary. 

Anatomically. Cysts in the Solid coil-like masses with small 

derma with straight processes of cysts scattered through them, and 
non-epidermic origin. of epidermic origin. 

Resemblances. — Both begin in early life, both encroach to an 
extent on the other's domain of distribution, both have milium 
on and between the lesions, both probably are of embryonic 
origin, slowly progressive, and do not involute. The cases of 
each type closely resemble each other. 

Prognosis. — In both lymphangioma tuberosum and epitheli- 
oma adenoides cysticum the tendency is to slowly increase in 
number and size. Spontaneous evolution cannot be expected. 

Treatment. — Operative measures are the only means of re- 
moving the growths. Electrolysis may be used to destroy them 
if the growths are in small numbers, but when numerous, curet- 
ting is probably the best means of removal; but a fine Paquelin 
or galvano-cautery might be used. 

In a face case Fordyce removed the majority of the larger 
tumors by the curette, and smaller one with a comedo-extractor. 
When the epidermis was broken, the tumors being loosely at- 
tached were readily extracted, leaving a slight scar. 

Benign epitheliomata of different clinical characters are re- 
ported from time to time. One such, by myself, was published 
in the Transactions of the Pathological Society for 1899. The pa- 
tient was a girl of ten, who had an aggregation of tumors single 
and compound, the single ones varying from a hemp seed to 
a pea, while the largest compound one occupied a square inch. 
They formed a vertical band an inch wide, extending from the 
middle of the right eyebrow to about an inch beyond the hair 
margin. The growths were soft to the touch, pale red, with a 
few vessels over the largest; they were neither tender nor pain- 



986 DISEASES OF THE SKIN. 

ful. There was a doubtful history of a blow before the appear- 
ance of the growths, which began when she was between three 
and four years, and some of which were still growing slowly. 
While the general clinical features were benign, the microscopi- 
cal characters suggested malignancy, and showed very active 
proliferation of the epithelial cells of the hair follicles and sweat 
ducts, but not of the sweat coils, sebaceous glands, or of the 
epidermis. The growths were probably of embryonic origin, 
as the hair follicles and sebaceous glands were imperfectly 
developed. 

ADENOMA SEBACEUM.* 

Synonyms. — Vegetations vasculaires (Raver); Naevi vasculaires 
et papillaires (Vidal). Naevi symetriques de la face (Hal- 
lopeau-Leredde). 

Definition-. — Neoplastic papules on the face, of congenital 
origin, but of later development. 

Rayer and Addison and Gull related the first cases, but it 
was not generally identified until the above designation was 
given by Balzer, who was the first to redescribe the affection 
without knowing of the previous cases. The cases now known 
are too numerous to be specially mentioned. I have met with 
several, and I could easily find many more, by visiting the 
idiot asylums, in which most of the cases are confined. The 
affection is, therefore, not so rare as it was at first considered to 
be, as the majority pass unrecognized into the hands of the 
neurologist rather than those of the dermatologist. 

The disease is practically confined to the face, occupying in 
the main the position of acne rosacea, i. c, the middle two- 
thirds. It is most abundant along the sides of the nose and the 

* Literature.— Author's Atlas, Plate LXXXVII. Rayer's Treatise, 
second edition; Willis' Trans., p. 996. cases clxxiv. and clxxv. ; and 
Atlas, Plate XX., Fig. 1. Addison and Gull on Vitiligoidea, Guy's Hospi- 
tal Reports, series ii., vol. vii. (1850), p. 267, and No. 262 model, Guy's 
Museum labeled " Lichen." Pringle, Brit. Jour. Derm., vol. iii. (1891), 
p. 1, a good resume of the subject, with colored plate, gives all the 
French cases. Caspary, Archiv f. Derm. u. Sypk., vol. xxiii. (1891), p. 
371, with colored plate. Internat. Derm. Cong., Vienna, 1892 — seven new 
cases by myself. There are several models in the St. Louis Museum. 



ADENOMA SEBACEUM. 9 8 7 

naso-labial folds, where it is semi-confluent in most cases; it is 
least on the forehead, where the lesions are scattered sparsely 
and without any arrangement, and some of the largest papules 
are often found here. The chin and sides of the cheeks occupy 
an intermediate position as far as the number of the papules 
is concerned. Their distribution is remarkably symmetrical, as 
a rule, but one of my cases was strictly unilateral in the usual 
position, and another oyer the lower jaw and outer side of the 
right cheek, while in Gaucher and Lacapere's case the disease 
was limited to a score of papules on the left temple, which began 
at the age of forty-eight. 

The lesions are roundish, convex papules, and most of them 
are from a millet to a hemp seed in size, but the extremes are 
a pin's point to a split pea. The majority of the lesions are of 
a bright crimson, from minute telangiectic vessels on and round 
them, but they may be quite colorless and slightly translucent, 
like little wax nodules, while on the forehead I have seen them 
of a brownish-red tint. They do not all pale on pressure, and 
the telangiectases vary much in extent, sometimes being almost 
absent, at others very abundant, in tufts and stars, and impart- 
ing a uniform red color. One of my cases corresponded to the 
last description, and Vidal's designation for the disease shows 
what a striking feature it was in his case. In my unilateral 
cases there was very little vascularity. 

In one case the papules were so small and insignificant that. 
if it had not been for the telangiectases, they would have es- 
caped my observation, the man having applied for a seborrheic 
eruption on the trunk; he was a bright, intelligent, healthy- 
looking man of twenty-six. 

A few of the lesions may be present at birth, or appear in 
very early life, and the others either appear gradually, or at 
some period such as puberty, and take on marked activity as 
to numbers; but individually they do not much increase in size 
beyond the limits stated. Subsequently the majority show very 
little change, though a certain number may undergo involution, 
leaving faint atrophic scars, which may disappear altogether in 
time. A large proportion show other signs of a defective skin. 
Numerous small fibromata, or their empty tags of skin, such as 
are common in old people, are scattered about, especially on 
the neck, and the larger .form may occur on the body. The tex- 



DISEASES OF THE SKIN, 

ture of the skin is coarse, and groups of hair follicles on the 
back have round them an infiltration or fibrous thickening, so 
that they form colorless hemp-seed-sized papules, or coalesce 
into flat, fibrous-looking patches, dotted over with large 
comedones. One or more of these flat, fibromatous patches * 
is usually to be found on the side over the iliac crest, either on 
the right or left side. Warts, true nevi, and pigmentation are 
also to be met with. 

Etiology. — The disease is of congenital origin, and all the 
marked cases show intellectual inferiority, a large proportion 
being chronic epileptics or imbeciles, and it is not uncommon 
in idiot asylums. Slight developments may occur apart from 
such conditions. One of my cases was an intelligent lady, set. 
forty-eight, and another, set. twenty-three; a third was a man 
of twenty-six; a fourth was a boy of eleven, above the intel- 
lectual average of his age and class. This boy had only a few 
papules, which had slowly developed for two years. One of the 
ladies had had one papule all her life, while the others had 
gradually developed ; so that the slight cases are of later develop- 
ment than the others. Nearly all cases occur among the poor. 

Pathology. — The disease is presumably an error of develop- 
ment in the shape of a congenital overgrowth of an adeno- 
matous character, developing from embryonic remnants in the 
skin, but in my experience affecting all the appendages, and 
therefore really a pilo-sebaceous hidradenoma. 

Anatomy. — This has been investigated by Balzer, Pringle, Caspary, and 
myself. Balzer found adenoid changes in one case in the sebaceous 
glands only; in the other, both in the sweat and sebaceous glands, he also 
found numerous small cysts. Pringle found adenoid changes in the 
sebaceous glands only, and no cysts. I examined portions of skin from 
the cheeks, forehead, and the fibrous lesions of the back. In the cheek 
lesions (Fig. 55), there was not the interpapillary growth Pringle found. 
The corium was much thickened, and the most conspicuous feature was 
the enormous number and size of the sebaceous glands, both single and 
compound; but the upper half of the corium was also studded with rudi- 
mentary hair follicles, while there was also an usually large number of 
sweat coils in the deeper portion, so that there was increased development 
of all the appendages of the skin situated at different levels. The 
papillary vessels were conspicuous, and there was moderate increase of 
the connective tissue. In the single large lesion from the forehead, which 

* These follicular fibromata are figured in the plate referred to in my 
Atlas. 



ADENOMA SEBACEUM. 



989 



clinically looked so different, the most striking distinction was the 
replacement of the enormous numbers of the hair follicles and sebaceous 
glands by fibrous tissue, of which the greater portion of the tumor con- 
sisted, with fragments of hairs and glands imbedded in it. The lesions 
of the back were seated at the hair follicles, round which dense fibrous 
tissue was developed in considerable quantity, the lesions being in short 
follicular fibromata. 

Diagnosis. — The most striking features are the occurrence of 
neoplastic, small, convex, telangiectic, deep-red nodules, semi- 
confluent, as a rule, along the naso-labial folds and the rest 




Fig, 55. — Adenoma sebaceum from cheek. X 2-in. Powell, 2-in. ocul. 

a, rudimentary hair follicles; b, sebaceous glands, large and numerous. 
Sweat coils are also present in abundance, but do not show with so 
low a power. 

discrete, but for the most part limited to the middle two-thirds 
of the face. They commence early in life, increase slowly in 
number and size, and there are generally other congenital de- 
fects of mind and body. The diseases mostly resembling it are 
epithelioma adenoides cysticum, colloid milium, and acne 
rosacea. 

Epithelioma adenoides cysticum is also of congenital origin, but 
the lesions tend to form irregular groups on the face, including 
the forehead, and the trunk may also be affected. The lesions 



990 



DISEASES OF THE SKIN. 



are not telangiectatic, and intellectual defects are not the usual 
concomitants. 

The two diseases resemble each other in both attacking the 
face, in both being probably of embryonic origin, and in their 
slow evolution and stationary behavior after development. In- 
deed, it would not be surprising if both these affections turn 
out to be slightly different clinical expressions of the same 
pathological process, a view which W. Pick * has also put for- 
ward quite recently. 

Colloid milium occupies the frontal and orbital regions. In 
adenoma sebaceum the lower half of the face is chiefly affected. 
Colloid milium nodules are not very numerous, and of a trans- 
parent yellow appearance. Adenoma nodules are very numer- 
ous, usually some shade of red, but occasionally white, and less 
translucent than colloid. Telangiectases are not a feature of 
the colloid, but are nearly always a very marked feature of the 
adenoma affection. 

From acne rosacea, the history of early development, the slow 
evolution and persistence of adenoma, absence of tendency to 
suppurate, and independence of digestive disturbance and sta- 
tionary behavior, would be sufficient. 

The idea of disseminated nodular lupus could only arise in the 
most telangiectatic cases of adenoma. Disseminated discrete 
nodules of lupus are as rare as adenoma sebaceum; the brown- 
ish-red color of lupus is not in any way due to telangiectatic 
vessels ; lupus nodules are not very numerous, not limited to any 
part of the face, and may even come elsewhere. Some of them 
grow to a much larger size than the largest adenoma nodule, 
and there is a decided tendency to undergo involution in the 
center while spreading peripherally. It produces also decided 
scars. Darier showed a case to the French Dermatological 
Society of " vascular and warty nevi," which was only distin- 
guishable from adenoma sebaceum by microscopical examina- 
tion, which showed vascular, but no sebaceous changes. 

Prognosis. — The tendency is for the lesions to slowly increase 
in number, but not much in size. Involution has occurred in 
some lesions, but permanency is the most constant feature. 

* " Ueber das Epithelioma Adenoides Cysticnm (Brooke) und seine 
Beziehung zum Adenom der Talgdriisen Adeno-Epitheliom," Walther 
Pick, Archivf. Derm. u. Syph., vol. lviii. (1901), p. 201, illustrated. 



CARCINOMA CUTIS. 991 

Treatment. — Xo internal or external medicament has the 
slightest effect upon them, and the only thing, therefore, is to 
remove them by surgical means. Hallopeau removed some of 
the growths by the curette and by scarification, but a year later 
some had recurred. Pringle tried to scoop or to bore out some 
of the nodules, but not very satisfactorily, on account of their 
depth. In the case of the lady, where the number of papules was 
not large, I successfully removed them by electrolysis, exactly 
in the same way as in occluding telangiectatic vessels ; the needle 
attached to the negative pole was introduced once for the small 
nodules, and several times for the larger, a current of three or 
four milliamperes being employed. In a very extensive case 
I excised a portion of the naso-labial fold, which was very 
prominent on each side, and also large lesions on the forehead. 
and obtained primary union; the rest was vigorously scraped 
with a curette, the nodules being very resistant. Great im- 
provement was effected, but several operations would have been 
necessary for anything like a complete removal of the lesions. 



CARCINOMA CUTIS. 

Cancer of the skin occurs in two varieties of scirrhus, the 
lenticular and tuberose, both of which are nearly always sec- 
ondary to cancer of the breast; melanotic cancer of the skin was 
formerly described; then the general view was that it was really 
sarcomatous, but Chambard * (1879), J- Hutchinson, Jr.f (1893), 
and Unna (1894) brought forward evidence that the old view 
was the correct one in a large number of cases, and Unna % 
stated that all pigmented cancers of mole origin were of the 
alveolar variety. A pigmented alveolar cancer of the lip of 
doubtful origin is recorded by Mott. Gilchrist also confirms 
these views. Whitehead records a case in which the tumor 

* Lancet, October 4, 1879, Annotation on Chambard's Article in 
Archives de Physiologie, Mott, Path. Trans., vol. xxxvii. (1886), p. 475, 
but he could not then feel sure it was carcinoma. Gilchrist, Amer.Joitr. 
Cut. Dt's., vol. xvii. (1S99), p. 117, many references; and Whitehead, abs. 
loc. cii., vol. xix. (1901), p. 149. 

f Hutchinson, Jr., Path. Trans., vol. xliv. (1S93), p. 148. 

% Unna, Berliner klin. Wochensch., 1893, Abs. Brit. Jonr. Derm., vol. 
v. (1894), p. 318. 



992 DISEASES OF THE SKIN. 

arose from an unpigmented mole, and was of the same structure 
as a melanotic cancer, but with no pigment. Epithelioma and 
its congeners, rodent ulcer and Paget's disease, are far more 
common and characteristically cancers of the skin. The first 
three forms concern the general surgeon more than the der- 
matologist, and require here only a brief notice. 

Carcinoma Lenticulare * is the most common form of cutane- 
ous scirrhus. It begins as small, shot-sized, flattish red papules, 
which enlarge to the size of a pea, bean, or even filbert, most of 
them projecting more or less above the surface, while others 
are subcutaneous. They are generally seated on a red or vio- 
laceous surface, which may be traversed by dilated vessels, and 
the skin is hard, smooth, and glistening. This induration has 
a border well denned to the touch, may extend over the whole 
or greater part of the thorax and abdomen, interfering with 
deep inspiration, like sclerodermia, and constituting the " can- 
cer en cuirasse " of Velpeau. The lymphatic circulation of the 
whole region is interfered with, lymphatic vesicles with copious 
clear fluid discharge are often present, the glands enlarge, and 
the limb adjoining becomes much swollen, preventing free 
movement. There may be severe lancinating pains, or only itch- 
ing and burning, at all events at first. In Morris' case the dis- 
ease commenced as diffuse hardness in the skin of the breast 
above the right nipple, and rapidly spread over the chest, the 
lymphatics standing out like radiating cords from the nipple; 
nodules appeared later. There was very little pain the first six 
months, but before her end, eight months from the onset, it was 
very great. As the nodules increase in number and size tney 
coalesce into large irregular masses, which sooner or later 
break down, ulcerate, and fungate, sometimes bleeding pro- 
fusely. The patient becomes cachectic, wastes, and dies ex- 

* " Lymphatic Infiltration of the Skin in Carcinoma of the Breast," J. 
Poland, Lancet, vol. ii. (1885), p. 338. A well-marked instance is pub- 
lished, with plates and histology, by Morrow and Robinson, in Amer. 
Jour. Cut. and Ven. Dis., vol. ii. (1884), p. 1; and two cases with histology 
and most of bibliography to date by Nevins Hyde in the Amer. Jour. 
Med. Sciences, March, 1892. Dubreuilh in 1889 published a case at Bor- 
deaux. Hutchinson in 1891, Amer. Jour. Cut. Dis., vol. ix. p. 181. 
Kaposi showed a case at the Derm. Cong, in 1892, and Morris another at 
the Derm. Soc. of London, November 13, 1895. 



CARCINOMA CUTIS. 



993 



hausted, or is hurried off by internal metastatic deposits or in- 
tercurrent inflammation. In Morrow's case, beside the char- 
acteristic papules and nodules, there was a multitude of milium- 
like bodies, the size and shape of wheat grains, and consisting 
of masses of epithelium, which at the periphery were vitally 
active, and in the center, fattily degenerating, and on pressure 
shelled out readily like comedones. They were abundant nearly 
all over the front of the trunk and in some regions of the back, 
and were the first change noticed by the patient, and " the most 
characteristic feature of the advancing part of the disease." 

These cancers are, as far as the skin is concerned, according 
to Unna and others, epithelial infarctions of the lymph tract, 
and not endothelial cancers. There is no essential difference 
between the so-called primary cases and those secondary to the 
breast, except that the primary are rarer and have a more super- 
ficial origin. Carless showed two cases at the Dermatological 
Society, secondary to cancer of the breast after removal, on De- 
cember 14, 1898. In one the process was commencing appar- 
ently as an erythema, spreading from the side operated on to 
the sound one; the red was not uniform, but somewhat in 
streaks. There was superficial induration to the touch, but no 
pain or tenderness. 

In the second there was recurrence of the cancer in the cica- 
trix, and from this there had spread a diffuse induration with 
well-defined red border and pale center, in which nodules could 
be felt. There were red papulo-vesicles in a band over the left 
nipple, from which lymph often flowed. The first patient was 
ruddy and plump and fifty-two years of age. The second was 
emaciated, the disease being much farther advanced. 

Carcinoma Tuberosum is rarer than lenticular. As the name 
indicates, the nodules are larger than the preceding variety, and 
may be of any size up to a hen's egg. At first deeply imbedded 
in the subcutaneous tissues and deep part of the corium, where 
they may be felt as very hard lumps, they gradually grow to- 
wards the surface, and the skin over them becomes tense and 
red, often with a brownish or bluish hue. They are often very 
numerous, scattered or aggregated into irregularly nodulated 
masses, and all tend to soften and break down into foul and 
painful fungating ulcers, which speedily exhaust the patient. 
63 



994 DISEASES OF THE SKIN. 

One of the worst cases of this kind, where the disease was 
primary in the skin, is reported by Roseler.* The nodules ap- 
peared suddenly, almost all through the panniculus adiposus, 
in a woman of fifty, increased rapidly in number and extent, 
until the whole body surface was covered with tumors from a 
pea to an tgg in size, over which the skin was at first stretched, 
and red, and then groups of yellow vesicles formed; then they 
all broke down into ulcers almost simultaneously, within six 
months from the onset, the patient sinking seven weeks later. 
There was no internal growth that could have been the starting- 
point. Korowin reported a case which began as a small-celled 
medullary carcinoma of the scalp and rapidly generalized in 
the lungs and skin; on the latter were two hundred nodules, 
some of which broke down and were indistinguishable from 
syphilitic rupia. 

Treatment for either form is unavailing. Euthanasia is all 
that can be aimed at. 



EPITHELIOMA.f 

Synonyms. — Epithelial cancer; Cancroid; Carcinoma epitheliale ; 
Fr., Epitheliome; Cancro'ide; Ger., Epithelialkrebs. 

Definition. — A malignant ulcerating new growth of the skin 
and mucous membranes, characterized by the development of 
heterologous epithelium in the corium and subcutaneous tissues. 

Epithelioma begins in most instances at the border of the 
mucous membranes and the skin, such as the lower lip. It may 
also begin on the mucous membrane only, as on the tongue, 
or on the free surface of the skin. It is with the disease, as 
manifested in the first and the last position, that we have chiefly 
to do. 

* Virchow's Archiv, vol. lxxii., p. 372, with plates. 

\ Literature. — Author's Atlas, Plate LXXVI., Figs. 4, 5, 6, 7. Paget's 
lectures on "Surgical Pathology," third ed., 1870, p. 700 — the best clinical 
account in the English Language, to which I am much indebted. Cornil 
and Ranvier's " Manual of Pathology," English ed., 1882, vol. i. p. 257. 
" Cancerous Affections of the Skin," Thin, 1886. " Der Epithelialkrebs," 
Carl Thiersch, 1865. Sebert among older writers; and Fabre Domergue 
(Paris: 1893), " Les Cancers Epitheliaux," and Unna's " Histopathology " 
for his special views may be consulted. 



EPITHELIOMA. 995 

There are three clinical varieties: (i) the discoid, (2) the papil- 
lary (both superficial), and (3) the deep-seated and infiltrating. 
These differ in clinical aspect, mode of development, and course, 
though the process is essentially the same in all, and the pri- 
mary growth is almost invariably single. In the superficial 
form the disease affects pretty uniformly all the tissues of the 
skin; in the papillary the papillae are the parts chiefly affected, 
while in the deep-seated the deep part of the corium and sub- 
cutaneous tissues are the primary seats of the disease. These 
distinctions only hold good for the early stages of the disease, 
before ulceration has taken place, as the superficial tends to get 
deep eventually. The disease may begin on apparently healthy 
skin, on the site of a scratch or other injury, or on previously 
diseased tissue. 

The primary epithelioma is usually single, but given the same 
kind of local irritation in more than one spot, or the same kind 
of antecedent lesion being multiple, and the epithelioma may 
also be multiple. In a patient of my own, a woman, aet. forty- 
six, epithelioma developed in the upper part of the chest and in 
the groin, in fungating nodules as big as a walnut. There was 
also a patch like a crusted lupus, which also turned out to be 
epitheliomatous. The glands in the axilla and groin were also 
cancerous. All the growths had developed on patches of lupus 
verrucosus, of which she had several besides those which had 
become cancerous. Recurrence took place a year later in the 
axillary one, which was again removed, but a year later she 
died from generalization in internal organs. 

A surgeon, aet. thirty-nine, whom I saw in 1895, had from 
the age of twenty-four been subject to small warts on the scalp, 
palms, and soles; a large crop came at once, and the others at 
various times. Several of these warts became epitheliomatous, 
and were removed at different times, and were pronounced bv 
experienced pathologists to be epitheliomatous. I removed 
one from near the anus and several of the warts. 

Dubreuilh * had a case of multiple epitheliomata of different 
type. Multiple epitheliomata are not uncommon, also, in xero- 
dermia pigmentosa, but they are of a special type. In secondary 
epithelioma there is no limit to the number of nodules; thus in 

* Archives Cliniques de Bordeaux, 1894, p. 333. • 



996 DISEASES OF THE SKIN. 

Finlay's * case, where the skin lesions were secondary to epithe- 
lioma of the stomach, there were scores of nodules on the trunk 
and limbs. 

Symptoms. — Superficial Discoid. Ill-defined papules or nodules 
covered with fine scales, continually renewed after removal, 
make their appearance, and when laid bare, look like bright red 
granulations. These gradually enlarge peripherally and verti- 
cally, and coalesce into a superficial, hard, round or oval, irregu- 
larly surfaced disc, of varying size, sharply defined at the border, 
which may be abrupt or sloping. The whole is movable with 
the skin at first, but afterwards becomes adherent to the sub- 
jacent tissues, and eventually, though it may be months or years, 
breaks down into ulceration. Sometimes the initial papular 
stage may be missed or unobserved, the disease apparently 
commencing as a fissure in the skin, and oozing with a thin fluid, 
which dries into a crust of a yellowish-green or black color. In 
these forms the disease is limited to the corium for a long time. 

The Superficial Papillary Epithelioma is most common on 
mucous membranes, especially those of the genitalia, on the 
scrotum and extremities, and often begins on a mole, wart, or 
other simple papilloma. A soft growth becomes indurated, the 
component papillae enlarge, and their epithelium proliferates 
both within and without. The papillomatous composition be- 
comes more and more evident, especially if the surface epithe- 
lium is washed away, and the papillae project considerably above 
the surface, and take various forms, cauliflower, fungiform, 
cylindrical, conical, and pyriform, according to the relative pro- 
portion of the base and apex of the growth, and the mode of 
grouping of the component parts. They are highly vascular, 
bleed easily, and are of a bright, florid color, thinly coated with 
opaque white cuticle, if in a moist position. Sometimes this 
form develops on the previously described plaque or nodule be- 
fore, or subsequent to, its ulceration. Both the papillary and 
discoid forms spread both laterally and vertically, but for a 
long time the firm fibrous tissue of the deep part of the corium 
may resist the downward extension, and the lateral growth is 
thus the predominating one. This may be very slow until ul- 
ceration sets in, which it inevitably does, generally before the 

* Path. Trans., vol. xxxiv. (1883), p. 102, with plates. 



EPITHELIOMA. 997 

patient comes under notice, commencing in the plaques as a 
diffuse excoriation, extending up to, but not destroying, the 
border of the growth, or from a fissure or wound in which the 
disease commenced. The discharge dries into a scab or dark 
crust, beneath and beyond which the ulceration extends. 

In the papillary form the center breaks down first, and ex- 
tends in all directions, but the new growth more than com- 
pensates for the advancing destruction. The resulting ulcer is 
generally characteristic; it is roundish, oval, or elongated, with 
uneven outline. The base and border are hard, and the latter 
is everted or undermined, and purplish-red, the thickness of the 
infiltrated part varying from one-twelfth to half an inch, in 
proportion to the extent of the ulcer. The granulations are 
small, bleed easily, are situated on a convex, irregular floor, and 
exude a thin, serous, peculiarly offensive discharge, which, un- 
less in a moist situation, dries into a crust, and is speedily re- 
newed after removal. This ulcer may be quite superficial, 
" cropping the papillary layer " only, as Wilson puts it, and 
even healing in the center, while it spreads peripherally. 
Eventually, however, the cancerous epithelium invades the deep 
layers; and when once the fibrous barrier is penetrated, the ma- 
lignant process proceeds comparatively rapidly through the fat, 
fascia, muscles, and even the bones, implicating the neighbor- 
ing lymphatic glands, which enlarge into hard nodules, and 
then coalesce into large nodulated masses, which soften in the 
center, the skin over them becomes livid often with superficial 
pustules, gives way, and deep foul ulcers are produced; the next 
series of glands gets involved, and in rare instances, the viscera, 
the lungs, liver, and even heart; the patient becomes cachectic, 
and soon dies, exhausted by the pain and discharge, or from 
some intercurrent malady. The whole disease lasts, on an 
average, four years when it is on the skin, the course being much 
slower in the superficial than in the deep form. The sensory 
symptoms which accompany these tumors and ulcers vary much. 
Sometimes they produce scarcely any inconvenience, at all 
events until ulceration has set in; or there may be stinging, 
pricking, or burning; but more frequently there is a dull aching, 
with exacerbations; or again, it may be severe and lancinating. 
The suffering is naturally much greater when it is about the 
mouth or anus. 



998 DISEASES OF THE SKIN. 

Deep-seated Epithelioma represents at an early period the 
condition only attained to at a later stage in the superficial 
form, and since its course, therefore, is much shorter, and more 
serious altogether, it is fortunately much rarer than the other 
forms. It is most common in the tongue and submucous tis- 
sues, but occurs also in the subcutaneous tissues, while the skin 
or mucous membrane over it is perfectly healthy at first. A 
good example, depicting the disease in the skin, is related by 
Paget. " A gentleman, set. sixty-four, had a tuberculated 
growth of ten weeks' duration on the side of the nose an inch 
in diameter, and gradually elevated up to about two lines above 
the surface; the skin over it was thin, adherent, and florid, with 
dilated vessels; the base of the growth rested on the bones, and 
involved the whole of the tissues to the periosteum, but was 
movable en masse; in the middle and most prominent part was 
a fissure nearly a line in depth, with black, dry borders, from 
which a very slight discharge issued." It was very painful, and, 
from the history, probably began in a small sebaceous cyst. The 
patient was well ten years after its removal. 

Sometimes the surface and deep tissues are simultaneously 
involved, but the deep parts are always most affected, and then 
form " a roundish, firm, or hard and elastic lump," but very 
little raised above the surface, on some part of which is a fissure, 
ulcer, or cancerously affected skin (Paget). The mode in which 
this form begins to ulcerate is thus described by Paget : " Either 
the skin over the tumor becomes adherent, thins, and cracks, the 
fissure for some time remaining dry and dark, while the ulcera- 
tion is extending below, or the central part softens, suppurates, 
or even sloughs through a comparatively small opening, while 
ulceration spreads laterally from the cavity; or, in secondary 
growths and under old scars, the cancer fungates through a 
sharply defined ulcer." 

The positions for epithelioma are, according to Paget, in the 
order of frequency — the lower lip fifty per cent, or more, the 
tongue and external genitalia of both sexes, more rarely at the 
anus, interior of the cheeks, the upper lip, palate, larynx, 
pharynx, and cardia, the neck and os uteri, the rectum, bladder, 
perineum, extremities, face, head, and trunk. Thiersch gives, in 
102 cases, 78 on the face, of which only 48 were on the lower lip. 
Roger Williams collected 329 epitheliomas of the lip from some 



EPITHELIOMA. 999 

of the London hospitals, and all except three were on the lower 
lip and in men. Epithelioma of the upper lip, therefore, is very 
rare, but there are many cases scattered through literature, and 
Eschweiler collected no less than 66 cases. When it does occur, 
although actually there are more males than females, it is only as 
3:2. It is also said to affect the left side oftener than the right. 
Certain occupations or customs may, however, modify the usual 
proportion; thus, in workers with paraffin, and chimney sweeps, 
it is abnormally common on the scrotum (chimney-sweep's 
cancer *) ; and it is common on the thighs in the inhabitants of 
Northern India, commencing in the cicatrices of burns, pro- 
duced by their custom of warming themselves over pots of hot 
ashes (T. Maxwell). 

Etiology. — Five out of six cases are males, and the great 
majority occur after the age of forty; it is rare under thirty, but 
soot cancer has been seen in children of eight years old, and 
Lebert f records a case of cancroid in a child of eight and a 
half, in whom it was almost congenital, and Selberg i a case at 
six months old. Heredity accounts for a small number only, 
about five per cent. The most potent factor as an exciting 
cause is long-continued irritation, though occasionally a single 
injury has been followed by it. It is thus that its preponder- 
ance in men, and on the lower lip, is accounted for, from the 
prevalence of smoking, even some of the few women victims 
having been smokers. Next to this, as starting-points, or pre- 
disposing conditions, are certain neoplasms, especially senile 
warts, horns, and other forms of papillary hypertrophy and 
horny thickening, such as may be seen in arsenical keratosis of 
the palm and sole (Hutchinson, A. Lane, and Hartzell).§ 
Other benign growths which may take on this form of malig- 
nancy are the so-called ichthyosis and leukoplakia linguae, moles 
and vascular nevi, adenomata, long-standing ulcers, such as are 

*See Butlin's " Lectures on Cancer of the Scrotum," Brit. Med. Jour., 
-vols. i. and ii., 1892, for a full account of the subject. 

f Roger Williams, Brit. Med. Jour., October 15, 1898, quotes several 
cases from eight years and upward. 

^Selberg, Yirchow's Archiv, vol. cxlv., p. 176 with references. The 
patient was a boy, and had a walnut-sized nodular ulcerating tumor on 
the right shoulder. It began as a red point when he was four weeks old. 

§" Epithelioma as a Sequel of Psoriasis," etc., Amer. Jour. Med. 
Sciences, September, 1899. 



iooo DISEASES OF THE SKIN. 

due to lupus vulgaris, erythematosus, or syphilis, and the 
atrophic skin or scars produced by those diseases, by xero- 
dermia pigmentosa, and by burns, which are particularly fre- 
quently the prey of the papillary form. Under the name of 
Lentigo melanosis, Hutchinson * has drawn attention to the 
development of epithelioma of the eyelid on persistent pigment 
patches, which are occasionally seen on the face, chiefly the 
orbit of old people, and have formed from an aggregation of 
lentigines, also from the melanotic whitlow, though the growth 
then is more frequently a sarcoma. In a case of Sheild's a mole 
was accidentally burned and a brownish discoloration spread all 
round it; after twelve years melanotic epithelioma developed. 
Galezowski has also reported a case of pigmented epithelioma 
from a mole on the eyelid. Sheild f also has published a good 
example of multiple cancer in the condition called by Unna 
" sailor skin," in which the lesions of exposure to weather se- 
verities become the seat of epithelioma. 

Pathology. — The essence of the epitheliomatous process is the 
development of epithelium, and its infiltration into the deeper 
tissues, where it does not normally exist, and where its pres- 
ence produces irritation and consequent inflammatory changes* 

There are two classes of epithelioma, the pavement and cylin- 
drical-celled; the latter affects only internal organs, such as the 
intestines, and need not be discussed here. Pavement epithe- 
lioma is divided by Cornil and Ranvier into the lobulated, the 
tubular, and the pearly; the first two only require considera- 
tion, the pearly form being a benign tumor. 

Lobulated Epithelioma is the common form and type of the disease,, 
and, as its name indicates, is composed of lobules. In a vertical section 
of a single lobule the component cells are seen to undergo the same 
changes, from the periphery to the center, as the normal epidermis does, 
from the lowest cells of the rete to the surface. On the outermost layer 
of the lobule, the cells are cylindrical (palisade cells): internal to this, 
they are polygonal and dentate (prickle cells); while in the center they 
are cornified and stratified, but, owing to their position, are compressed 
into lobes, with concentric layers like an onion (" bird's-nest bodies"), 
in the center of which multi-nucleated and colloid cells are sometimes 
found. The lobules are separated by a stroma supporting the vessels, 

* Archives of Surgery, vol. iii. (1892), p. 310. " Lentigo Melanosis," and 
sequel, vol. v. (1894). p. 253, with colored Plate CVI. Dubreuilh and 
others have since published cases as Lentigo Maligna Senilis. 

f Lancet, January 7, 1899, p. 22, with colored illustrations. 



EPITHELIOMA. iooi 

which never penetrate into the lobules. Both stroma and cells vary in 
composition and structure; the stroma may vary both in vascularity and 
density, and be either embryonic, mucoid, or fasciculated — i. <?., adult 
connective tissue — or all three together, in varying proportions; the cells 
may be colloid, horny, occasionally melanotic,* but seldom mixed in the 
same tumor. There is, however, another process, of an inflammatory 
kind, produced by the irritating influence of the cancerous epithelium on 
the tissues; the stroma between the lobules and the tissues immediately 
surrounding the advancing epithelium is infiltrated with round cells, 
most, if not all, immigrant cells; these cells separate and break up the 
fibers of connective tissue, and the tumor may disintegrate or slough 
from obliteration of the vessels, either by endarteritis, or by pressure on 
them by the epithelial lobules and leukocytes. 

Lobulated epithelioma is developed from the epidermis of the skin or 
mucous membranes, or from the new embryonic tissue near it; whether 
it is by proliferation of the epithelial cells, or, as Rindfieisch thinks, by 
the influence of such cells on those of the connective tissue in the neigh- 
borhood, is a matter of dispute, but, on the whole, the balance of evi- 
dence is in favor of the first view. At all events, the result is a great 
downgrowth of the interpapillary processes of the rete, and secondary 
processes bud off from these laterally, as well as terminally, and becom- 
ing detached appear as isolated epithelial masses, often in globes in the 
corium and deeper tissues, so that it is at this stage again possible to 
recognize their point of departure. Buds may also come off from the 
hair follicles, and Cornil and Ranvier think from the sebaceous glands 
also, the cells increasing from the periphery to the center, pushing the 
fat cells to the center, and finally extruding them; Thin, however, 
doubts this, though, a priori, it seems probable enough. In the sweat 
glands, by a similar process, solid cylinders of epithelium are formed, 
which send out buds in the adjacent embryonic tissue, and unite into 
a network ; some of these cylinders, which consist of small pavement 
cells, enlarge, and, by continued multiplication of the cells, which also 
become larger toward the center, " bird's-nest bodies " are ultimately 
formed from these also, and get separated like those from the rete. 
When this development from the sweat glands is primary, and stops 
short of the first stage of the process described in the development 
of the cylinders from sweat glands, i. e., does not go on to epidermic 
evolution, we have tubular epithelioma, the surrounding stroma being 
embryonic mucous or fibrous tissue; these tumors are less malignant 
in the skin than in the lobulated form, though sometimes they relapse or 
extend to the lymphatic glands, and cannot, therefore, represent rodent 
ulcer. 

Unna divides cancers of the skin according to their general 
structural characters, into: I. Fungating; 2. Cylindrical; and 
3. Alveolar. 

* Paget, loc. cit., p. 722, a case in which the disease began in a pigmented 
mole. 



1002 DISEASES OF THE SKIN. 

The term cylindrical of group 2 does not correspond with 
cylindrical-celled cancers, but refers to the grouping of the cells 
into cylinders. He makes several subdivisions of these main 
groups. His views are original, and founded on the careful ex- 
amination of seventy cases, and are therefore deserving of con- 
sideration, but are too elaborate to be discussed here, and the 
student must refer to his " Histopathology." The usually ac- 
cepted views are here given. 

Diagnosis. — The most characteristic features, when it usually 
comes under notice, are those of a chronic, painful ulcer, most 
frequently on the lower lip, with indurated, everted, or under- 
mined edges; and sooner or later, secondary implication of the 
neighboring lymphatic glands. The lesions of rodent ulcer, 
syphilis, lupus, acuminate warts, and rhinoscleroma, are the 
diseases from which it has to be distinguished. 

The distinctions from rodent ulcer are mainly clinical, and are 
given under that disease. 

From syphilitic nodules and gummatous idecration. — The lesions 
of syphilis are much more rapid in their course, and often pain- 
less; there is no hardness or new growth round the ulcers, 
which are generally multiple, sharp-edged, and punched out; 
and the pus is abundant and yellowish, while that of cancer is 
scanty, viscid, and sanious. In rare instances iodid of potas- 
sium may be given to decide a doubtful case, but it must be 
remembered that true epitheliomata may get smaller from the 
absorption of inflammatory products under iodids, but they 
never disappear. 

Epithelioma may be distinguished from a chancre on the penis 
or lip by the history and duration of the lesion, which will be 
short in the case of a chancre, as compared with the cancerous 
ulcer. 

In lupus vulgaris the lesions are more often multiple, and 
more likely to begin in childhood, or at least in young persons. 
There is an absence of induration, while there are nearly always 
some of the characteristic, soft, brownish, semi-translucent 
nodules near the ulcer; the pus also is more abundant, and not 
bloody or offensive. The possibility of epithelioma being 
grafted on an old lupus must be borne in mind. 

Since epithelioma so often starts from a wart, it is important 
to recognize the change as early as possible. If a wart, which 



EPITHELIOMA. 



1003 



has previously been quiescent, becomes uneasy or painful, be- 
gins to grow and bleed, or becomes indurated at the base, in a 
person past middle life, it should at once be removed. 

Prognosis. — This is always unfavorable unless complete re- 
moval can be effected at an early stage, but is much more so 
in some cases than others. 

The unfavorable circumstances are: the advanced age of the 
patient, the tumor being situated on mucous membranes, or 
other places unfavorable for complete removal; if on the skin, 
its being deep-seated, and secondary growths in lymphatic 
glands or elsewhere, the course having been unusually rapid. 
Favorable conditions are: the patient being still in the prime 
of life, short duration of the tumor, moderate infiltration, the 
growth being superficial, its being away from mucous mem- 
branes, ulceration being slight and superficial, and the absence 
of secondary implication of the glands. As to the course, it 
may in the deep-seated be fatal in two years, or in three or four; 
in the superficial it may go on for several years, until the ulcera- 
tion begins to penetrate into the deeper tissues, when its down- 
ward progress becomes more rapid, and the same as that of 
the deep-seated variety. The tubular variety is nearly always 
very slow, but it is impossible to distinguish it clinically. 

Treatment. — Removal, speedy and complete, is the only safe 
course to pursue. This may be effected by the knife, caustics, 
galvano-cautery ecraseur, or actual cautery, according as the 
cancer is superficial or deep, and to the condition of the tissues 
round. Whatever is done should be done thoroughly, and even 
the apparently sound tissues immediately round should also be 
removed. Caustics are only suitable for the superficial form; 
the solid potassa fusa may be bored into the tissue in and round 
the growth, neutralizing any excess of the potash by dilute 
acetic acid; the pain is of comparatively short duration.* A. R. 
Robinson of New York is a very great advocate for this. Other 
caustics are chlorid of zinc, Vienna or arsenic paste, according 
to the formulae at the end, and Kaposi recommends pyrogallic 
acid 5ij to §j of lard. Chlorate of potash, resorcin, acetic acid, 
fuming acid, nitrate of mercury, methylene blue, pyoktannin, 
lactic acid, etc., have advocates, but whatever is used should 
be applied so as to remove the entire growth, a superficial 
* International Journal of Surgery \ July, 1892. 



1004 DISEASES OF THE SKIN. 

action being worse than useless. All of them, in my opinion, 
are far inferior to the knife, and should only be used where the 
patient refuses an operation, or for some other reason it is im- 
possible to excise the growth. The galvano-cautery ecraseur 
is sometimes useful when the growth cannot well be reached 
by the knife, as occasionally in eyelid growths, but it is not now 
used for the tongue, as septicemia so often followed. 

Scraping with the sharp spoon is still practiced by a few on 
the superficial growths, but in my opinion cannot be too 
strongly condemned where excision is possible; it is not only 
very likely to fail, but recurrence is speedy and aggravated. 
Unless the removal can go well beyond the disease, recurrence is 
always only too likely to occur, but hopes of eradication may be 
entertained, if this can be effectually dealt with as soon as it 
makes its appearance. 

Lassar * has brought forward three cases of epithelioma 
which had healed soundly under the administration of five-drop 
doses of liquor arsenicalis three times a day. There would be 
no harm in trying it in inoperable cases, or in the early stage 
when the case could be watched, so that if the growth was not 
arrested excision could be resorted to. Stoker recommends his 
method of oxygen constantly applied to the growth. While I 
should not waste valuable time in an operable case, it has ap- 
peared to relieve pain, and may therefore be used in inoperable 
cases. The Rontgen rays may also be used, but these are more 
applicable to rodent ulcers, under which the procedure is de- 
scribed. 

PAGET'S DISEASE OF THE NIPPLE.f 

Synonym. — Malignant papillary dermatitis (Thin). 

Symptoms. — This affection was first described by Paget in 
1874, from fifteen cases. While at the onset it resembles a sim- 
ple inflammation, before very long it develops into scirrhous 

* Berlin klin. Wockensch., 1893, p. 537. Abs. Annales Derm, et de 
Sypn., vol. v. (1894), p. 255. 

\ Literature — St. Bart's Hosp. Rep. 1874, p. 83, the best clinical 
account. For histology, Butlin, Med. Chir. Trans., vol. lix., p. 108, and 
vol. lx., p. 153. Thin, Med. Chir. Soc, 1880, and Brit. Med. Jour., 
May 14, 1881. Duhring and Wile, Amer . Jour. Med. Sciences, July, 1884, 
with a good summary of previous observations. " Maladie de Paget,'* 



PAGET S DISEASE OF THE NIPPLE. 1005 

cancer of the whole breast. It is generally limited to the nipple 
and areola, but in Jamieson's case extended all over the breast 
and axillary region, and was nearly as extensive in G. T. El- 
liot's case. It occurs in women from forty to sixty years, and 
has been compared to an eczema, having, as Paget describes it, 
" a florid, intensely red, raw surface, very finely granular, as if 
the whole thickness of the epidermis had been removed. From 
such a surface, on the whole or greater part of the nipple and 
areola, there is always a copious, clear, yellowish, viscid exuda- 
tion." The border is sharply defined, and even slightly raised, 
and very soon, if not at the very first, there is marked indura- 
tion of the tissues, about a line in thickness, which feels, as 
H. Morris expressed it, " like a penny felt through a cloth." It 
is accompanied by tingling, itching, and burning, but with no 
disturbance of the general health. 

In a case of mine, in a very early stage, the site of the nipple 
was in a condition of excoriation, partially covered with a thin 
crust, which when detached left a shallow raw surface; the bor- 
der was well defined, and when the diseased area was pinched 
up, very distinct but superficial induration could be felt. The 
nipple itself had disappeared. The condition had been develop- 
ing two years, but there was no actual sign of cancer. Sheild's 
case * was the opposite of this, the superficial ulceration measur- 
ing 11 by 10 1-2 inches. It had been present six years, and 
although fungating in one part, the glands were not enlarged. 

In Paget's fifteen cases, all within a year or two developed 
scirrhus of the breast, one of the first signs being retraction of 
the nipple. There is, however, no doubt that the apparently 
inflammatory condition may exist for several years before it 
becomes recognizably cancerous; in H. Morris' case it was six 
years, in Duhring's case ten years, and in Jamieson's twenty 
years. 

I have met with a precisely similar condition on the scrotum f 

by L. Wickham, " These de Paris," 1890 (G. Masson, publisher) — an excel- 
lent monograph, with colored plates, setting forth the psorosperm theory 
and giving the bibliography. Jamieson, 3d ed., p. 537. G. T. Elliot, 
" Paget's Disease treated with Fuchsin," Amer. Jour. Cut. and Gen.-Ur., 
Dis., vol. x. (1892), p 272. 

* Author's Atlas, Plate IX., Fig. 3, early stage. Plate LXXVL, Fig. 8, 
late stage in scrotum. 

f The case is published, with colored plate and histology, in Path. Soc. 



1006 DISEASES OF THE SKIN. 

of a man, aet. forty-seven. After remaining as a raw surface 
for two years, nodules developed in the center of the ulcer. 
Pick has seen it on the glans penis, and Sheild * had a case 
affecting the skin over the pubes. Neisser, Pospelow, and 
Tarnowsky have also met with it in the penis and scrotum, 
Winfield and Dubreuilh f have observed it on the vulva, and 
Darier and Couillaud on the arms and perineum. 

Pathology. — The important point to decide is, whether the in- 







'^^^1~ -{■■:■'-:% 



m$*m 



■tut 



I 




3 

■'1 



Fig. 56. — Pseudo-psorosperms in my case of Paget's disease of the 
scrotom (after Wickham.) 

A. Two pseudo-psorosperms very B. A single psuedo-psorosperm, 
highly magnified in the rete highly magnified, in the middle, 

mucosum. of an interpapillary process of 

the epidermis. 

flammation is at first of a simple kind, or whether it has the 
impress of cancer upon it from the onset. 

Thin, who has made very careful microscopical observations 
on four cases, believes that they demonstrate that it is cancer 
from the outset, hence the name he proposes; but in none of his 

Trans., vol. xl. (1889), p. 187. Pick's case is reported in Deutsch. med 
Zeitung, November 5, 1891; pseudo-coccidia were found in the epithelium, 

*Both of Sheild's cases are reported by Rolleston and Hunt with 
microscopical examination under Dermatitis Maligna, in Path. Soc. 
Trans., vol. xlviii. (1897), p. 211. 

f Brit. Jour. Derm., vol. xiii. (1901), p. 407. Dubreuilh mentions nearly 
all previous cases. 



PAGET'S DISEASE OF THE NIPPLE. 1007 

cases was the disease in an early stage. The clinical facts are 
opposed to this, as it is difficult to believe that a cancerous dis- 
ease would continue for ten and even twenty years, in some 
cases, before the cancerous nature declared itself in the whole 
gland. Comparison has been aptly made with the chronic sur- 
face inflammations of the tongue in syphilitics, and the so-called 
ichthyosis linguae, in which epithelioma so often develops, 
though only after the irritation has lasted for many years. 

Darier's * discovery of psorosperm-like bodies in this disease, 
which were also found by L. Wickham in my case affecting the 
scrotum (Fig. 56), has lost much of its interest, since it is now 
admitted even by Darier himself that they are only metamor- 
phosed epithelial cells; their constant presence, however, is of 
some diagnostic importance. 

Anatomy. — The anatomy has also been investigated by Butlin, Thin, 
Wile, and Dnhring, Schweinitz, Porter, and others, with on the whole 
general agreement. The boundary between the diseased and normal 
tissue is sharply defined by the proliferating downgrowth of the rete, and 
by the abrupt termination of the cell infiltration. In the affected area 
the epidermis is lost to a varying extent, entirely in some parts; but while 
the surface part is gone, there is downgrowth of the interpapillary part, 
ultimately compressing and even sometimes obliterating the papillae. 
These latter are at an earlier stage densely infiltrated by masses of lym- 
phoid cells, and there is more or less perivascular infiltration in the upper 
layer of the corium, while in the middle and lower layers are alveoli of 
epithelial cells, significant of cancer in the advanced cases. The first 
malignant change, Thin says, takes place in the lactiferous ducts; hence 
his name of " duct cancer." They are stuffed and dilated with squamous, 
not columnar, epithelial cells. This proliferating process spreads 
along the smaller ducts, and the distended walls give way, extrud- 
ing the epithelial mass; and by its own proliferation and by its 
effect on the neighboring tissues, cancer develops outside them as 
well as within, spreading at first upward and outward, and then 
into the gland structure itself. To Rolleston, however, it appeared 
to be derived from the stratum Malpighii, but differed from an 
ordinary epithelioma. The anatomical resemblance of my case to 
rodent ulcer was very striking. The easiest way to demonstrate the 
pseudo-coccidia is to scrape the surface, and treat the scrapings with 
iodin or bichromate of potash, after Darier's plan, or to soak the scrap- 
ings in liquor potass<e and mount in glycerin jelly, as recommended by 
J. Hutchinson, Jr. They can be readily seen with a half-inch power. 

* These observations have been confirmed by Bowlby, who examined 
thirteen cases, Med. Chir. Trans., vol. lxxiv. (1891), p. 341. 



ioo8 DISEASES OF THE SKIN. 

They are round or oval, .03 mm. long, have a double contour on section 
from the shell-like envelope, and are found in the thin, epithelial layer 
of the raw-looking surface. 

Diagnosis. — It is highly important to decide as soon as possi- 
ble as to the nature of what is, at first sight, only an eczema of 
the nipple. This may not be possible at the commencement, but 
when the disease has lasted for some time, in a woman past 
the climacteric period, and has been rebellious to treatment, the 
differences between Paget's disease and eczema, which have 
pointed out by McCall Anderson and others, begin to be recog- 
nizable. 

Eczema of the nipple is most common during the child- 
bearing period, especially during lactation; Paget's disease oc- 
curs usually after the climacteric. In eczema, while there are 
frequent Assuring, desquamation, and exudation, there is not 
the intense red, raw, granulating appearance which is brought 
into view by the removal of the crusts in Paget's disease, in 
which there are none of the papules, vesicles, and pustules, with 
the exacerbations which characterize eczema. In eczema the 
tissue is soft, there is no induration, and the edge is ill-defined. 
In Paget's disease there is superficial induration about a line 
in thickness, to be felt " like a penny through a cloth." The 
border is sharply defined, and may be slightly raised. Itching, 
which is an early sign in eczema, is a late one in Paget's disease. 

In all doubtful cases search for pseudo-psorosperms should 
be made by one or other of the methods described under 
" Anatomy," for their presence is constant in Paget's disease, 
and they have never been found in eczema. 

When the nipple becomes retracted the nature of the disease 
is no longer doubtful. Shooting or aching pains begin to ap- 
pear, the breast gets hard, lumpy, and knotty, and before long 
the neighboring glands become involved. 

Prognosis. — Unless the disease is recognized and energetically 
dealt with the prognosis must be that of cancer; but if the dis- 
eased tissue be thoroughly removed or destroyed, a perfect 
cure may be looked for. 

Treatment. — In the early stage, if the diagnosis is doubtful, the 
treatment would be the same as for eczema of that part, to 
which the reader is referred. In a woman past the middle age, 
if the part will not heal with soothing and protective measures, 



RODENT ULCER. 1009 

irritant remedies should be avoided. Mild and superficially act- 
ing caustic remedies only do harm; and if the dangerous char- 
acter of the disease be suspected, either the breast should be 
removed, or caustics, sufficiently powerful to destroy the whole 
of the affected tissue, should be selected. The best of these is 
the chlorid of zinc paste (Caustics, F. 11) which should be 
spread thickly on lint, the exact size of the diseased area, kept 
on four or six hours, and the slough poulticed off with wet boric 
lint, under oiled silk; or the surrounding tissues may be pro- 
tected by lint wet with vinegar, and solid caustic potash, forcibly 
bored into the diseased area until it is thoroughly destroyed. 

Elliot's case healed completely with an ointment of fuchsin, 
beginning with a grain, gradually increased to five grains to 
the ounce. These applications, however, should be reserved for 
cases which refuse operation, and few women can understand 
the necessity for so radical an operation as removal of the entire 
breast when there is only a small sore. Probably the removal 
of this sore alone, rather widely and deeply, as for an epithe- 
lioma, would be sufficient in an early stage, and it might be 
more easy to obtain consent for the minor operation. 



RODENT ULCER.* 

Synonyms. — Jacob's ulcer; Cancroid ulcer; Ulcus exedens; Noli 
me tangere; Fr., Ulcere rongeant; Ulcere chancreux; Ger., 
Der flache Krebs. 

Definition. — A chronic cancerous ulceration of the skin, nearly 
always on the face, with a tendency to much destruction of all 
the tissues, very little to new growth, and none at all to sec- 
ondary infection. 

The disease was first described by Jacob of Dublin in 1827; 
it is still a matter of dispute as to whether rodent ulcer is a 
separate disease or only a clinical variety of epithelioma, but, 

* Literature. — Author's Atlas, Plate LXXVI., Figs. 1, 2, 3, showing 
different stages. For clinical features. Paget's "Surgical Pathology," 
loc. cit., and Hutchinson, Med. Times and Gazette, i860, " A Clinical 
Report on Rodent Ulcer." For pathology, Thiersch, loc. cit., and Thin, 
loc. cit .; Collins Warren, Boylston prize essay, Boston. 1872; T. and C. 
Fox, Path. Trans., vol. xxx. ; Sangster, Brit. Med. Jour., October 22, 

64 



ioio DISEASES OF THE SKIN. 

as it is usually clinically distinguishable, it requires separate 
description. On the Continent rodent ulcers are usually called 
epitheliomata. 

Symptoms. — The disease is not very rare from the age of forty 
onwards. It chiefly attacks the orbit, sides of the nose, or any 
part of the upper two-thirds of the face, occasionally the scalp, 
neck, and still less frequently, other parts also. It begins as 
a pimple or trifling excoriation, or as a soft, flat-topped, or 
indented nodule, which the patient calls a " wart," but the sur- 
face is smooth, and it is a brownish-red, solid, moderately firm 
mass, often with a dilated vessel coursing over it. This growth 
may remain unchanged for many years, but sooner or later it 
begins to break down, and when once it has begun to ulcerate, it 
continues surely, though it may be very slowly and even inter- 
mittently, to spread laterally and vertically, eating through all 
the tissues, both soft and hard, and destroying perhaps the 
greater part of the face, and eventually the patient's life, by 
the exhaustion induced, but never implicating the neighboring 
glands, or leading to secondary deposits — remaining, in short,, 
a local disease from first to last. Throughout its course, al- 
though there is variable amount of new growth, preceding and 
accompanying the ulceration, unlike epithelioma, the new 
growth is slight compared to the destruction which is the pre- 
dominating feature. Occasionally, however, the preliminary 
nodule is as large as a hazelnut or walnut before it breaks down. 
Bowlby speaks of one of twenty-six years old with a tumor on 
the nape as large as a Tangerine orange; and Rushton Parker 
had a case of a large rodent tumor which grew on a bald scalp 
for nine years without ulceration. 

The ulcer is rounded or oval, with a characteristic edge,, 
which is slightly raised, rounded or " rolled," firm, not everted 
or undermined, with sinuous outline, of a yellowish-red color, 
with vessels coursing over it, but with none of the warty 
growths seen round an epithelioma. The center, in long- 
standing cases, is much depressed below the surface, though at 
unequal levels if the ulcer is large, but, as a rule, with little 

1882; Hume, Brit. Med. Jour., January 5. 1884; Paul, Brit. Med. Jour., 
May 2, 1885. A. Bowlby, an analysis of sixty-six cases. Path. Soc. 
Trans., vol. xlv. (1894), pp. 153 and 163. There are many other interest- 
ing communications on Rodent in this volume. 



RODENT ULCER. ion 

tendency to form granulations, the surface being comparatively 
smooth or traversed by furrows. There may, however, be 
granulations in one part while excavation is going on at an- 
other, and in rare instances it may fungate and bleed, but, as 
a rule, the discharge is scanty and odorless, and while there is 
but little tendency to new growth, indicated by the thin layer 
of indurated tissue at the base and border, there is still less to 
permanent repair, though attempts at cicatrization sometimes 
occur when the ulceration has actually eaten away the diseased 
edge. The cicatrization is still more marked in the very super- 
ficial variety, of which I have seen a few instances; the ulcer is 
shallow, of uniform depth, with a sharp-cut edge, the whole 
looking as if a piece of skin had been punched out, and resem- 
bling Paget's disease; in these cases there may be some healing 
in one part and ulceration in another, or even temporary 
cicatrization of the whole under simple protective treatment. 
In one such case, a woman of eighty, the more typical form, 
with raised, rolled edge, and deep ulceration, subsequently de- 
veloped on the cicatrized surface, and about two years later 
appeared the crateriform ulcer to be presently described. The 
superficial variety is said to be more frequent on the temples * 
and forehead, and may be deep in one portion. 

The ulcer is very slightly, if at all, spontaneously painful. 
Occasionally, f typical epithelioma has developed on typical 
rodent ulcer, and then all the secondary consequences of the 
more serious disease may supervene. Apart from such an acci- 
dent, rodent ulcer may go on, if left undisturbed, for ten, fifteen, 
or twenty years. 

The following represents the common run of cases, except as 
regards age and position: 

A gentleman noticed at the age of twenty-four a flat, slightly 
raised, soft, reddish, molelike growth, the size of a shilling, on 
the side of the neck; it remained unaltered for eleven years, 
when, after being chafed by his collar, it began to ulcerate, and 
at the end of nine years more was only two inches by one and 
a quarter in area, and presented the typical characters of rodent 

* Vide case of Leader, Fig 3, loc. cit., Author's Atlas. 

f Bowlby disputes this, doubting even its possibility, and speaks of 
rodent ulcers with round lumpy edge as well as the large tumor referred 
to with rodent structure. 



1012 DISEASES OF THE SKIN, 

ulcer as seen in its more common position on the side of the 
nose. 

Although it is true that the vast majority of cases (seven- 
eighths, Bowlby) are situated on the upper two-thirds of the 
face, a few occur in the lower part of the face, and in rare 
instances it occurs quite away from the face and neck. I have 
seen it affecting the ear and nape and just above the sacrum. 
Bowlby also records it on the back, J. Hutchinson, Jr., on the 
forearm and in the groin ; and I have also had a groin case which 
developed from a hair follicle, Pigg one in each groin, Rolleston 
near the umbilicus, B. Robinson on a male breast, and C. Fox 
on the sternum.* 

Rodentlike epithelioma is generally single, but may be multi- 
ple. I have seen two rodents on the face twice; three once. 
Bowlby met with a case with six rodents, five on the face and 
an enormous one on the back, and Colcott Fox's case had five 
on the face and scalp. 

A unique mode of development in my experience was the 
formation of a yellow plaque f on the temple of a woman, which 
began when she was thirty-five. It began as a white spot the 
size of a hemp seed, but when first seen was a well-defined disc 
the size of a shilling, slightly raised, quite flat and uniform, and 
of distinctly lemon-yellow tint, with a few small dilated vessels 
converging from the periphery, and enlarged very slowly and 
underwent no other change. After three and a half years, when 
it was the size of half a crown, it became more prominent at the 
border in the lower part and ulcerated, and its rodent ulcer 
nature was then diagnosed. It was excised well beyond the 
growth in January, 1899, but recurred again and again, the last 
operation in January, 1902, being the fourth. Histologically it 
was a typical rodent. 

Under the name of " crateriform ulcer "J Hutchinson de- 

* Path. Soc. Trans, for 1893, 1894, 1896, and 1898. 

f The case was shown in the plaque stage at the Dermatological Con- 
gress in London in 1896; but no one could then make a diagnosis. 

\Path. Soc. Trans., vol. xl. (1889), p. 275, with colored illustrations of 
three cases. In F. J. Behrend's Atlas (Leipzig, 1839), this affection is 
depicted under the name of cancer globulosus, Plate XXIII., Fig. 5. The 
lesion is on the side of the nose near the inner canthus. It is evidently 
copied from Rayer's Atlas, Plate IXV., Fig. 6, where it is called cancer 
tubercule ulcere. 



RODENT ULCER. IO i 3 

scribed a variety of malignant epithelial ulcer which affects the 
same regions, on the upper part of the face, as ordinary rodent 
ulcer; it occurs in the same class of people, but runs a much 
more rapid course, growing as large in a few months as ordi- 
nary rodent would in as many years. It begins as a bossy, 
rounded lump, which rapidly attains a considerable size, and 
presents a somewhat conical summit. At this summit ulcera- 
tion takes place, and with exceedingly little suppuration or 
obviously destructive inflammation, a cavity forms. The walls 
of the crater thus formed are very thick and firm; the growth 
is much less vascular and less succulent than that of rodent, 
and while it is easy to scrape the latter away, it is impossible 
to do so with the crateriform ulcer. It has no tendency to 
fungate or become warty. Nearly all the cases that I have seen 
have developed on a previous rodent ulcer of the ordinary type, 
but Hutchinson has met with them as primary growths, and 
the following is evidently a case of the kind. A woman, aet. 
thirty-three, noticed, five months before she was seen by me, 
a small nodule at the right inner canthus; it enlarged to the 
size of a large pea, and then broke down in the center, and 
looked exactly like a rodent in the wart stage which had just 
given way, and such it was diagnosed to be at the Dermatologi- 
cal Society, even by Hutchinson himself. On removal, how- 
ever, its structure was found to be exactly that of typical epi- 
thelioma. All the " crateriform ulcers " hitherto examined 
have been found to be of the typical epithelioma, and not of 
the usual rodent-ulcer type of structure. The case Fig. 4 in my 
Atlas, from the history, began as a rodent; unfortunately, the 
specimen was lost before it was examined microscopically. 
Whether these secondary cases are true epitheliomata or not, 
when once a rodent takes on this condition it grows with great 
rapidity compared to its former indolence. 

Etiology. — I have analyzed 50 consecutive private cases and 
25 hospital ones, all in my own practice. Of these, in private 
there were 32 males to 18 females, while in the hospital there 
were only 10 males to 15 females; together this would make 
42 males to 33 females. In Bowlby's 66 cases collected in the 
surgical department of St. Bartholomew's there were 40 males 
to 26 females, so that, as regards sex, the males predominate 
as about 5 : 3. 



1014 DISEASES OF THE SKIN. 

The age of onset * is of interest in my 50 private cases, 
where this point could be determined most accurately. One 
began under 30, 1 under 35, 7 between 35 and 40, 14 began 
between 40 and 50, 10 between 50 and 60, 9 between 60 and 70, 
8 between 70 and 80. Altogether there were 9 under 40, and 

41 over that age. The hospital cases were in the same ratio, 
5 under to 20 over 40. Bowlby's figures give a greater propor- 
tion under 40, viz., 26, to 40 over. Moreover, while he had 
only 9 out of 66, I had 18 out of 50 which began over 60. 
Speaking generally, it is a disease which usually commences 
after 40 and is rare under 30. 

Roger Williams \ gives the average age as 44 for males and 

42 for females; mine work out much higher. 

The earliest date of onset I know of was 12 in a case of 
Sequeira's. The latest, set. 87. \ Bowlby, Roger Williams, and 
others have also recorded cases under 20. Local irritation of 
an apparently innocent abrasion or pimple is often the starting- 
point of the disease, and even when there is a true rodent 
nodule, it may remain without ulceration for years, if it is not 
irritated nor injured. A certain number date from a local in- 
jury; a very few from unpigmented or other moles; a few from 
scars. Beyond this we are ignorant of its causation. A can- 
cerous family history is not a factor, as it is in epithelioma. 

Pathology. — All are agreed that it is a cancer of epithelial 
origin, but opinions vary as to its nature. Nearly all § Conti- 

* Norman Walker, without stating the number of his cases, says rodents 
usually begin about the age of 40, and thinks that statistics to the con- 
trary have only regard to the age of the patient when first seen. The 
above shows that is not the case, only 4 were under 40, 9 came first when 
40-50, and 36 over 50. 

f The details of his figures are in the Middlesex Hospital Reports for 
1888. In his youngest case a pimple appeared on the left temple at the 
age of fourteen, which soon broke down; it took eight years to reach the 
size of a sixpence, but in five more was as large as a half-crown; it was 
then cauterized, and spread rapidly; then it was scraped, and two years 
later had become epitheliomatous, and was again removed; she died of 
it at the age of thirty-six. Brit. Med. four., October 18, 1890, p. 895. 

JOne of Bowlby's cases. The patient was ninety-four when first seen, 
and on the lower part of the helix of the right ear was a hard nodulated 
growth the size of a fig, with rounded and uneven edges and irregular 
surface, but it was not ulcerated. It began as a pimple, was diagnosed 
as epithelioma, but had a rodent structure. 

§ Unna classes it as the styloid variety of his cylindrical form of epithe- 



RODENT ULCER. 



1015 



nental writers regard it as a variety of epithelioma, and this 
view is supported in this country by Moore, Hulke, Hutchinson, 
and others, and by Collins Warren and his followers in Amer- 
ica. Investigators have differed as to which of the appendages 
of the skin have given origin to it. Thus Thiersch and Butlin 
and Paul * (chiefly) believe that it starts from the sebaceous 




Fig. 57. — Rodent ulcer in the " wart" stage. Obj. 2 in., ocul. 2 in. 

<a, central mass of epithelial cells beginning to disintegrate; b, b, similar 
smaller cell masses imbedded in the fibrous stroma c\ d, d, portions 
of sebaceous glands. 

glands, Thin and Norman Walker, from the sweat glands, and 
Tilbury and Colcott Fox, Sangster and Hume and Bowlby, from 
the hair follicles. 

In the general discussion at the Pathological Society, while 
there was as much difference of opinion as ever as to which 
appendage could lay best claim to be the seat of origin, there 
were few dissentients from the proposition that it was a sub- 
epidermal growth with the structure of a glandular cancer quite 
distinct from the squamous-celled epithelioma. Most admitted 
that the rete might be involved at a late period, and that then 
epitheliomatous growth and behavior resulted. 

lioma. The views of Continental writers generally are of less weight, 
as they see but few cases compared to English authorities. 

*Paul, Path. Soc. Trans., vol. xlv. (1894), p. 164. From thirty-three 
cases he considers it to be subepidermic chiefly from sebaceous glands, 
perhaps sometimes from sweat coils, never from hair follicles. In one 
of my cases in the groin the growth certainly started from the hair 
follicles. 



1016 DISEASES OF THE SKIN. 

Dubreuilh and Auche,* who have examined fifty cases, state 
that it usually starts in the pilo-sebaceous follicle at the level 
of the sebaceous gland; that in rare instances it starts from 
the epidermis itself near the follicle, but that it never starts in 
the sweat glands. 

Rodent ulcer may therefore be defined as primarily a cancer 
of the appendages of the skin, and probably does not arise 
exclusively from any one of them. As a late event, the rete may 
also be involved, but unless this happens the greater part of 
the growth is made up of granulation tissue, the epithelial pro- 
liferation being comparatively moderate. 

The cells of rodent ulcers are undoubtedly smaller than those of any 
epidermic epithelioma, and Thin, in addition, draws the following dis- 
tinction: In rodent ulcer the nucleus of the cells is fairly uniform in 
size, the cell protoplasm is scanty and not granular, and the cell wall is 
not discernible; further, the cells never enlarge into the flat horny cells 
of epithelioma, they never become prickle cells, never form nests, do not 
retain the dye of eosin, soften in the center of the cell masses by mucoid 
degeneration, and the cell infiltration and disorganization of the corium 
are much less than in epithelioma, while the cell infiltration and mitoses 
do not go far beyond the cell growth. 

Diagnosis. — It is not difficult to distinguish a typical rodent 
from a typical cpithcliomatoas ulcer. In the first the ulcer is 
always away from mucous membranes on the upper part of the 
face; there is very little new growth, and much ulceration. The 
course is much slower, comparatively painless, and there is no 
lymphatic implication or secondary deposition; the edge of the 
ulcer is smooth, flat, or rounded, and seldom much raised. In 
epithelioma the ulcer is generally on or near a mucous mem- 
brane, the new growth always predominates over the ulcera- 
tion, the course is much more rapid, it is often very painful, 
and sooner or later it involves the lymphatics, and even affects 
internal organs, and a warty-like growth is often present at the 
edge of the ulcer. When, however, epithelioma is quite away 
from the mucous membranes, its course is often very slow, with 
but little tendency to lymphatic implication, and the amount 
of new growth is less, and it then becomes difficult, sometimes 
impossible, to speak positively as to the nature of the ulcer. 

* Annales de Derm, et de Sypk., vol. ii. (iqot), p. 705. Abs. in Brit. 
Jour. Derm., vol. xiv. (1902), p. 150. A good article of seventy-four pages. 



RODENT ULCER. 



1017 



This is well exemplified in the case related above under 
Crateriform Ulcer. 

From syphilitic and lupus vulgaris ulcers, the age of the pa- 
tient, its origin from a single nodule, the very slow course, and 
its being nearly always single, the absence of deposit in the sur- 
rounding tissues, and the very scanty discharge, would distin- 
guish it. The same distinctions hold good between rodent and 
strumous ulcers, except that there is no induration in the latter. 

The rodent nodule may be mistaken for a soft wart or small 
fibroma. The age and development of the growth, its shining, 




i^K Ct 



Fig. 58. — Rodent ulcer. A portion of Fig. 57 under a higher power. 
Obj. £-in. Ross, ocul. 2 in. 

a, a small epithelial cell mass imbedded in the fibrous stroma b, which is 
infiltrated with round cells. The outline of the epithelial cells is for 
the most part undiscernible, only the nuclei being visible. 

waxy aspect, and the almost invariable presence of dilated ves- 
sels over it should seldom leave any doubt. 

Prognosis. — Although, as a rule, very slow in its progress, if 
left to itself, it spreads either continuously or with short in- 
tervals of quiescence, and besides producing wide and deep de- 
struction, will eventually exhaust, and, directly or indirectly, kill 
the patient. Persevering treatment may, however, effect a per- 
fect cure; and I have seen a case of an old woman who had two 
ulcers, one of which healed permanently. Temporary healing 
is quite common. In a case of extensive ulcer, with exuberant 
growth at the border, a great portion healed soundly under 
iodid of potassium, though the rest, which looked the same, had 
a typical rodent aspect under the microscope. 

Treatment. — Like ordinary epithelioma, free removal of the 
ulcer, going well into the healthy tissues round, is the only safe 



1018 DISEASES OF THE SKIN. 

course; its synonym, "noli me tangere," is a standing warning 
against half measures, which only irritate the ulceration into 
greater activity. 

The knife, erasion, caustics, and the galvano- or Paquelin's 
cautery, are the means to be employed, and of these, one or 
other of the first two is generally preferable, according to the 
position. After erasion, which should only be employed where 
excision is impracticable, it is safer to swab the part freely with 
chlorid of zinc solution, 5j to the §j of water, or, better still, the 
application of the Middlesex chlorid of zinc paste (Caustics, 
Fig. n), and although recurrence is very likely to take place 
in some part, if a similar treatment be resorted to without delay, 
complete eradication may generally be obtained. In extensive 
ulcers removed with the knife, Wolfe's * method of transplanta- 
tion, from the arm or other convenient part, may be employed 
to replace the removed portion. Where operation is refused 
Unna's resorcin plaster may be tried, renewing it each day. 
Boeck, Unna, and others have been successful with this method. 
In the use of caustics and other remedies the observations on 
the treatment of epithelioma may be referred to. The " crateri- 
form ulcer " of Hutchinson requires free excision without delay, 
and then it is not likely to recur. 

Where operation is refused or is otherwise unsuitable the 
Rontgen rays are a good alternative for many rodents. A ten- 
inch coil, a six-inch tube, a mercurial jet interrupter are the 
apparatus required. All but the ulcer is protected by a lead- 
foil mask, the tube should be about four inches from the ulcer, 
and a current of four amperes employed. From ten to fifteen 
daily exposures of ten minutes each are usually required, stop- 
ping at once if any erythema round is produced. The ulcer 
generally heals very satisfactorily, but requires watching, as it 
is very seldom that permanent cure is obtained except by repeti- 
tion of the exposures, though a smaller number than at first are 
usually sufficient. 

The Finsen light has also been used with success, but the 
results have not been so good in most cases as with the Rontgen 
rays. 

*Esmarch, La,7icet y June 8, 1889, and A. Ceci, Brit. Med. Jour., April 
16, 1892, illustrated with portraits of successful cases, show the advan- 
tages of the method. 



SARCOMA CUTIS. 1019 

SARCOMA CUTIS.* 

Sarcoma of the skin is generally due to metastasis, f or in- 
vasion from other parts or organs, but it may be primary in the 
skin structures, single or multiple, pigmented or non-pigmented. 
They exhibit a tendency to general spreading and metastasis to 
glands and internal organs, and lead to the death of the patient. 

Clinically, they may be divided into pigmented and non-pig- 
mented sarcoma, the latter of very variable histology. 

They are round, spindle-celled, or giant-celled,J with a delicate 
reticulum, and numerous vascular tunnels through them. 

Another group of malignant tumors, but differentiated from 
true sarcoma, are those histologically characterized by lymphoid 
cells, in which are included leukemic and pseudo-leukemic 
(Hodgkin's) tumors and the malignant lymphoma. 

A second group is called " Sarcoid," a sort of limbo for cases 
of doubtful pathology, which is sought to be established by 
Kaposi, Boeck, Johnston, and others. It includes multiple 
idiopathic hemorrhagic sarcoma, sarcomatosis (Kaposi), and 
multiple benign sarcoid (Boeck). Clinically and histologically 
they have not much relationship to each other, and I have also 
placed here the obscure " Mortimer's malady." 

Melanotic Sarcoma is the most common form, and all mela- 
notic growths have for a long time been considered as of this 
nature. As already mentioned, however, Chambard, J. Hutch- 
inson, Jr., Unna, and Gilchrist have recently shown that this is 
not the case, and Unna states that all growths with metastasis 
which starts from pigmented moles are really melanotic car- 
cinomata, and have an alveolar structure, and should be called 
nevo-carcinoma.§ The clinical behavior is the same as the form 

* Unna's " Histopathology." 

f " Sarcoma and the Sarcoid Growths of the Skin," by James C. John- 
ston, a good thoughtful article, Brit. Jour. Derin., vol. xiii. (1901), p. 241. 

% The giant-celled are said to be derived from the bone marrow, and 
therefore secondary, but I am not sure that this is always true. 

§ Whitfield, Brit. Jour. Derm., vol. xii. (1900), p. 267, discusses the 
question with most of the references. To these may be added Hodara's 
and Audry's paper, and one by Tailhefer, also published in the Jour, des 
Maladies Cut., vol. xi. (1899), P- 6 5! vol- xiii. (1901), p. 798; and vol. ix. 
(1897), p. 129 respectively. 



1020 DISEASES OF THE SKIN, 

which is Still admitted to be melanotic sarcoma, which usually 
starts from the choroid coat of the eye, but the back and sides 
of the hands and feet, and the genitalia, are common positions 
for the primary growth; on the foot the common position is 
" under the middle of the tread of the heel," perhaps from injury 
from a nail in the boot. The following case, although more 
rapid in its course than usual, illustrates the clinical features. 

Mrs. K.,* aet. fifty-eight, with a strong family history of can- 
cer, noticed what she thought was a blister from friction on the 
outer side of the right foot, below the malleolus. From this 
developed, in the course of five months, a fungating, slightly 
pigmented growth, the size of a crown-piece, which was ex- 
cised by Mr. Rivington, and proved to be a melanotic sarcoma; 
eight days later melanotic growths appeared on the outer side 
of the right thigh; in a week more they sprang up round the 
wound of operation, and from that time fresh tumors appeared 
daily, but almost confined to the right lower limb, the lymphatic 
glands remaining free; a few came on the trunk and head of 
the same side. Each tumor first made its appearance as a flat- 
tish papule, the size of a hemp seed, and the color of a half-ripe 
mulberry ; in two days it showed signs of pigmentation, and very 
soon became of a bluish-black color, like a Hamburg grape, 
discoidal, of any size, up to about half an inch in diameter, and 
raised about an eighth of an inch above the surface. The tu- 
mors by continual multiplication became confluent in some 
places, and then formed large, flattish, irregularly lobulated 
black masses, which soon broke down, fungated, and discharged 
sanguineous pus, or at times bled freely. She died, with symp- 
toms of visceral implication, in less than four months after re- 
moval of the primary tumor. 

The following case illustrates another mode of development. 
A surgeon, aet. forty-five, had noticed a pigment spot under the 
clavicle, half an inch across, twenty-two years ago; it grew 
slowly for twenty years, but more rapidly a year and a half be- 
fore I saw him, when it was an oval patch two and a half by 
one and a half inches, slightly raised with irregular border of 
deep black color for one-eighth of an inch, then a purplish zone, 
and a nearly normally colored center. 

Six weeks before he came a small part which had been 
* Plate LXXVIL, Fig. i, of my Atlas represents her case. 



SARCOMA CUTIS. 102 1 

slightly sore and scaly for a year ulcerated, and formed a granu- 
lar elevated patch half an inch in diameter, and there was slight 
enlargement of the glands in the axilla. The patch was excised, 
and was found to have a pigmented mole structure as a whole, 
and there was also a point of pigmentation in one of the ex- 
cised glands. The fungating growth was what is usually classed 
as melanotic sarcoma, but the. epithelial elements showed that 
it was a melanotic carcinoma with alveolar structure. There 
was very little pigment in the growth itself, doubtless from its 
being only six weeks old. In the generalized cases a slate-blue 
pigmentation of the whole surface simulating argyria * some- 

% 



^ 



Fig. 59. — Pigmented cells of a nevo-carcinoma. Zeiss D. D. 10-inch tube. 

times supervenes towards the end, associated with melanuria. 
(Wickham Legge, I. Trumbull's cases.) 

A special and insidious form is that described by Hutchinson 
as " melanotic whitlow " ; f at first it appears as a chronic ony- 
chitis often due to injury, with very little pigment, like a " lunar 
caustic stain," and that only at the border; it very gradually de- 
velops into a fungating tumor, with still only a little pigment; 
the nail is thrown off, and generalization soon occurs. Nunn J 
reported a case in 1880. 

Galloway § read a good paper on the subject at Montreal in 
1897, based on a case in which the disease was just commencing 
on the foot. It would probably have developed like the first 
text case. See also Lentigo Melanosis. 

* A case with many peculiarities and a different form of pigmentation 
was published by Abraham in Brit. Med. Jour., January 2, 1892, p. 13. 
f Brit Med Jour., March 13, 1886. 

\ Melanosis of the little finger. Path. Soc. Trans., vol. xxxi. (1880), p. 299. 
% Brit. Med. Jour ., October 2, 1897, p. 873, with numerous references. 



1022 DISEASES OF THE SKIN. 

The treatment for melanotic sarcoma is the same as for the 
non-pigmented form, but the prognosis is rather worse. In all 
melanoses prevention is emphatically the best course, and every 
melanotic deposit, whether of mole or other origin, should be 
promptly and widely removed as soon as it shows any sign of 
activity. 

In the Non-pigmented Sarcoma Cutis the tumors may be 
in enormous numbers, amounting to several hundreds, or there 
may be a few only, or even a single one. In size they may be 
from a lentil to a bean, or larger, firm to the touch, not neces- 
sarily tender, and the skin over them is reddish or brownish or 
bluish-red, and perhaps slightly scaly. Very many of the cases 
reported as sarcoma cutis are really subcutaneous, and the skin 
over them more or less movable, and often of normal color. 
Where they are very thickly placed they may form plates or 
masses, with a more or less nodular surface. They are, how- 
ever, scarcely two cases alike in either clinical features or 
structure. 

A case I saw with my colleague, A. Barker, is an example of 
a single tumor in the first instance. 

A round-celled sarcoma developed on the site of a " Scinde 
sore " on the cheek of a young army surgeon, three months after 
the development of the sore. Seven months later it formed a 
fungating mass one inch across, and a third of an inch above 
the skin, from which it rose abruptly, but infiltration round 
could be felt for a quarter of an inch. He died within a month 
of its removal from visceral generalization. 

T. Norton records a very similar tumor on the leg with ooz- 
ing of blood. Glandular infection had taken place before its 
removal and generalization produced a fatal result in eight 
months. 

The following is an instance of a moderate number of tumors: 
A healthy-looking man, set. forty-seven, noticed on his right 
cheek what he took to be a small mole, which irritated him and 
was scratched, and then grew to the size of a hazelnut. This 
was removed at the county infirmary, but grew again, and when 
seen fifteen months from the first onset was as large as ever, 
and there were numerous smaller secondary growths, extending 
nearly to the angle of the lower jaw. Many of the smaller 



SARCOMA CUTIS. 1023 

growths coalesced with the base of the larger one, but there 
were isolated hemp-seed to pea-sized tumors beyond it. They 
were of a livid color, and the central one was scabbed, and bled 
easily. The tumors were firm and not tender, but were some- 
times painful. There was a solitary enlarged gland under the 
angle of the jaw, but the general health was unaffected. The 
tumors were excised by Mr. Heath, but in six months the man 
returned with a few fresh tumors on the cheek, and enormous 
enlargement of the submaxillary lymphatic glands. The date 
of his death is unknown. The tumors excised first by Mr. 
Heath were those of alveolar sarcoma, those of the second 
recurrence were round-celled sarcomata. 

In a case of multiple sarcoma in a man of sixty, brought to 
me by Dr. Peter Cooper, the lesions were erythematous, slightly 
raised discs from half to an inch in diameter, the smaller flatly 
convex, the larger flatly concave, firm, and more tumorlike to 
the touch than to sight; in many of them the follicles were very 
prominent. There were no sensory symptoms. A few only ap- 
peared first on the chest, but after about nine months they be- 
gan to develop more rapidly, and in three months were very 
numerous all over the trunk and upper segments of the limbs, 
and slightly on the lower segments; later the testicles, lym- 
phatic glands, and viscera became involved, the skin tumors dis- 
appeared, and the patient died fifteen months from the first ap- 
pearance of the skin growths. From the general and extreme 
enlargement of the lymphatic glands lympho-sarcoma was 
diagnosed, but no microscopical examination was allowed. 

There is a rare form of spindle-celled sarcoma, described by 
Hutchinson as " recurrent fibroid of the skin." " It begins usu- 
ally in the lower extremities, grows slowly at first, but recurs 
rapidly and persistently after removal, however wide the in- 
cision, and ultimately generalizes, fungates, forms blood cysts, 
and destroys the patient." 

In another form of Fibro-Sarcoma * a single tumor may 
be present for many years, growing very slowly, and when mul- 
tiplication takes place it is limited to the neighborhood of the 
original growth for a long time, ultimately the tumors become 
widely spread. 

*Ionides showed a case of this kind to the Derm. Soc. of London, Brit, 
Jour. Derm., vol. viii. (1S96), p. 439. 



1024 DISEASES OF THE SKIN. 

A remarkable case, with myriads of tumors with " myeloid 
cell " structure (Fig. 60), was shown by me at the Dermatologi- 
cal Congress in London in 1896. The tumors developed soon 
after an attack diagnosed as acute rheumatism in a man, aet. 
thirty-nine. They appeared first on the hips on March 3, then 
about the elbows, then all over the back, and then on the legfs. 
On March 6 there were a few on the face. When I saw him with 
Mr. Sworn on April 29 there were congeries of coalesced tu- 
mors on each elbow, forming a nodular mass some two inches 




Fig. 60. — Myeloid cell sarcoma from a tumor excised from the right elbow, 
in diameter; near this mass were isolated tumors from a hemp 
seed to a filbert in size, but the majority were roundish, very 
distinctly raised, of a brownish-red color, and of firm consist- 
ence, but quite painless and not tender. Over the buttocks and 
hips there were many scores of similar growths, a few of them 
three-quarters of an inch in diameter; near the anal cleft there 
was a uniform brick-red infiltration in which tumors were not 
traceable. Nearly the whole of the back below the spines of 
the scapulae was a mass of nodular infiltration of a purplish-red 
tint made up of myriads of small tumors. On the trunk in 
front there were only a few tumors, but there was a purplish 
infiltration like that of the back, at the lower part of the abdo- 
men. There were very numerous tumors at the lower part of 
the buttocks, a moderate number at the back of the thighs, and 
scarcely any below the popliteal spaces. There were only a few 
small tumors in front and inside the thighs, but some were like 
those on the elbows and the knees. 



SARCOMA CUTIS. 1025 

There was effusion of fluid into the sheaths of the tendons at 
the wrists, knees, and tuberosity of the tibia. His wife said there 
were a few lumps in the scalp as far back as July, 1895, anc ^ 
that they had increased in size and number since. A tumor 
evoluted quite suddenly in a night, enlarged to a pea or bean, 
and sometimes involuted again, leaving brown spots. The pa- 
tient was not cachectic, but as he had much pain in his joints, 
salicin in fifteen-grain doses three times a day was prescribed. 
In a week it was noticed that many of the tumors had become 
smaller, and in a week or two more scores of them had disap- 
peared, and many others were in process of absorption, and 
cavities could be felt in the larger ones. 

The infiltration in the back diminished greatly, and when 
shown at the Congress a very large part of the disease had dis- 
appeared. Unfortunately he has been lost sight of since. 

Kohler and Johnston * report a case very like the above 
clinically, but histologically it was a small spindle-celled sar- 
coma. 

Perrin and Leredde f report a generalized case of giant-celled 
sarcoma, but the clinical features were different from my case, 
and the lesions much less numerous. 

Hallopeau and Jeanselme had a case which began in the hand, 
and spread along the lymphatics simulating an infective lym- 
phangitis. But these examples are enough to show how varia- 
ble are the clinical symptoms, except in one particular, that 
sooner or later, and in the majority sooner, the tumors general- 
ize in the viscera, and the end is then near at hand. 

In rare instances multiple sarcoma may be congenital. Dr. 
Jordan Harvey brought for my diagnosis the dead body of an 
infant, in whom there were nodular growths at birth, about sev- 
enty pea- to bean-sized nodules of purplish color over the bodv 
and face. Pernet's J examination showed them to be small 
round-celled sarcomata with large vascular tunnels in them. 
Ramdohr had a case with twelve growths on the body and a 
few on the face and in the kidneys. 

*" Idiopathic Multiple Sarcoma of the Skin," Amer. Jour. Cut. Bis., 
vol. xx. (1902), p. 5. 

\ Annates de Derm, et de Syph., vol. vi. (1895), p. 1038. Abs. Brit. Jour. 
Derm., vol. vii. (1896), p. 147. 

\Path. Soc. Trans., vol. liii. (1902). 

65 



1026 DISEASES OF THE SKIN. 

Treatment had always been futile, a fatal issue appearing in- 
evitable, until Kobner tried arsenical injections. Fowler's solu- 
tion was used, diluted one to two of distilled water. The first 
case was a girl of eight, who had more than three hundred 
tumors, from a hazelnut in size downwards, scattered nearly all 
over the body. Two and a half to four drops of the solution 
were injected once a day, and after three months the dose was 
raised to seven and a half and then to nine drops. The tumors 
gradually disapeared, leaving at first brown, slightly scaly 
patches, and finally even these disappeared: the child was quite 
well a year later. 

A similarly successful case, in a woman, set. thirty-one, is re- 
ported by F. D. Shattuck. The disease was first observed in 
the submaxillary lymphatic glands, and subsequently enormous 
numbers of pea-sized tumors developed in the skin. The dose 
was at first four, and later six minims of Fowler's solution 
diluted; the treatment was continued for about eight months, 
and she was quite well a year later. 

Although, as was to be expected, this treatment has failed in 
many instances, others in addition to Kobner and Shattuck have 
had equal success, amongst which Sherwell's case may be spe- 
cially mentioned.* Lassar f has gone further, and brought for- 
ward a successful case of melanotic sarcoma, treated by liq. 
arsenicalis internally; and Pospelow has had a good result in a 
case of round-celled sarcoma, in which he gave both the solu- 
tion and Asiatic pills. My own case of involution of tumors 
under salicin is in the same direction, and suggests a microbic f 
origin for sarcomata. 

Coley's fluid is a solution of erysipelas toxin with that of 
bacillus prodigiosus, and was suggested to him by the ameliora- 
tion often produced by an attack of erysipelas. It was recom- 
mended to inject the fluid subcutaneously, beginning at half to 
one minim and increasing to six minims. Febrile reaction 

*Sherwell, Abs. Brit. Jour. Derm., vol. v. (1893), P- I2 5> original in 
Amer. Jour. Med. Soc, October, 1892. 

f Lassar's case is reported in Annates de Derm, et de Syph., vol. v. 
(1894), p. 1118. 

X This hypothesis is strengthened by the existence of infective sarco- 
mata in dogs, which can be transplanted. B. Smith and Washbourn, 
Brit. Med. Jour., December 17, 1898, p. 1807. 



SARCOMA CUTIS. 1027 

occurs and sometimes dangerous symptoms. While there have 
been some successes, the general opinion is against its employ- 
ment, and at all events it should be reserved for desperate, in- 
operable cases.* It is possible that an improvement in the char- 
acter of the fluid, and in the method of using it, may give a 
better prospect. 

M. C. Beretta f brings forward evidence of amelioration from 
anti-cancerous serum injection, but this requires further investi- 
gation. At all events there are indications that the treatment 
of sarcoma is not quite so hopeless as was formerly the case. 

Sarcoma Capitis, or Endothelioma Capitis (Turban tumors). 
A peculiar form of tumor, in rare instances attacks, and is lim- 
ited to the hairy scalp; in extreme cases, covering the whole 
scalp like a wig. 

The first case on record is by Morrant Baker J under the 
name of " withering sarcoma of the scalp." The patient, a man, 
aet. twenty-four, received a blow on the head, and the tumors 
developed soon after, one ten inches in diameter was removed, 
and proved to be a fibro-sarcoma. Some of them underwent 
involution. 

Kaposi § showed the model of a similar case with billiard-ball 
to orange-sized tumors, very numerous and forming a wiglike 
covering over the entire scalp; the tumors had been growing 
for forty years in a man, set. sixty; he had some similar tumors 
on his back. His daughter had for a year noticed pin's-head 
to pea-sized tumors developing on the head, face, and trunk, 
which were proved histologically to be of the same nature, and 
Kaposi called them endothelioma congenitale. He referred to 
a case of Poncet published in the Revue de Chirurgie (1890). 

Oro's || case, also after injury, was a spindle-celled sarcoma in 

* Vide Sheild, Butlin, Moulin, Battle, and Shattuck, etc., Brit. Med. 
Jour., January 23, 1897, p. 193; January 30, p. 299; August 13, and Decem- 
ber 3; and Lancet, November 19, 1898, Med. Soc. Report, 1898, etc. 

f Annotation, Lancet, August 27, 1898, p. 565. 

% Museum of Coll. of Surg., Skin Sect., No. 313-14 of 1895 Cat. Two 
wax models. There are also models and drawings in the St. Bart.'s 
Museum of this case. 

§ " Comptes Rendus de Cong. Int." Rome, 1894, p. 135. Illustrated in 
Plates CCXXXI. and CCXXXII., Kaposi's Hand Atlas, as a form of 
Molluscum. 

I Giorn. Italiano d. mal. ven. e d. Pelle., Fascic. II., 1896. 



1028 DISEASES OF THE SKIN. 

a man, set. seventy-four, and was more like Morrant Baker's 
case, but is described as a single tumor with lobes which cov- 
ered the head like a turban. 

In a case reported by Colin * of Portland, U. S., the patient 
was a woman, set. fifty-two. The growths had been forming 
since she was twenty-four years old, and many had been re- 
moved; a grandmother was said to.be similarly affected. Struc- 
turally they consisted of oval -cells in alveoli, and of fusiform 
cells and fibrous tissue. Barrett f of Melbourne has published 
another case of a woman, set. sixty; and two of her daughters 
had similar growths. He called them multiple sudoriparous 
adenomata. Spiegler's J paper on " Endothelioma of the Skin," 
without giving a new case, focuses five of the previously pub- 
lished cases — Kaposi's (two: father and daughter), Poncet's, 
Ancell's, and Cohn's. 

Their family prevalence suggests that they are really of con- 
genital origin though often late in development. They are not 
malignant in their behavior and are not true sarcomata, and 
some say they are " endotheliomata." 

Idiopathic Multiple Hemorrhagic Sarcoma § is very rare in 
this country, only two indisputable cases having been reported, 
both by Pringle. Kaposi, however, who first described the dis- 
ease in 1879, nas na d thirty cases; in Naples it is not so rare, De 
Amicis having had over fifty cases; and it is frequent in 
Northern Italy. In Russia, || Stoukovenkoff of Kief had ten, 
and others have been met with. Cases in other European coun- 
tries have occasionally been reported, and a few in America by 
Wigglesworth, Fordyce,lf Jackson, Breakey, Hyde, etc. Se- 

* Amer. Joicr. Cut. Dis.,vo\. x. (1892), p. 393. 

f Barrett, Brit. Med. Jour., February 6, 1892. 

JSpielger, Archiv f. Derm. u. Syp/i., vol. J. (1899), P- l6 3» with illus- 
trations. 

§ Kaposi himself has proposed to substitute " hemorrhagic " for " pig- 
mented" as the name for this disease, to prevent its being confounded 
with the other form of pigmented sarcoma. Plate IV. of the Internat. 
Atlas gives a good illustration and references to previous cases, by 
Schwimmer. 

|| Semenow read a paper at the Moscow Congress, 1897, on these ten 
cases, of which there is a good abs. in Brit. Jour. Derm., vol. x. (1898), 
p. 64, 

T[ Fordyce's cases are in Jour. Cut. and Gen.-Ur. Dis., vol. ix. (1891), 



SARCOMA CUTIS. 



029 



queira * has published what he considers to be a case of this 
disease, while admitting that it is of the same type as those 
cases called by Hutchinson symmetrical purple congestion of 
the skin (vide p. 143). 

Tandler's f case appears to me to belong to erythema 
elevatum diutinum (vide p. 142). 

The pigmentation is due to hemorrhages into the skin. The 
following account is taken chiefly from those of Kaposi and 
Funk. J; It attacks first the palms, soles, or backs of the hands 
and feet, either simultaneously or with short intervals, then 
the legs and forearms, the thighs and arms, and reaches the 
face and trunk in two or three years. The ears are sometimes 
affected at an early stage. It commences, with or without pre- 
ceding edema, as diffuse cyanotic spots which pass into infiltra- 
tions, and these into nodules; or it may commence as nodules. 

They are roundish, from a shot to a pea or bean or even a 
cherry in size, reddish-brown or bluish-red, irregularly discrete 
or in small or large groups. They are tender, and their devel- 
opment is attended with pain, which may radiate up the limb, 
and there may also be pain from the tension, for besides the 
tumors, in some cases, there is a diffuse elephantiasis — like 
thickening of the extremities, especially of the legs, so that the 
limb is stiff and distorted, and in the case of the hand over- 
extended, so that the patient is completely crippled. When the 
trunk is affected — and the whole cutaneous surface may be 
involved — the skin and subcutaneous tissue are diffusely infil- 
trated, hard as a board, and immovable, with a nodular surface, 
and of a dark violet-brown or plum color (Funk). In one- 
fourth of the cases nodules of infiltration are present on the 
glans penis, prepuce, and scrotum. 

The tumors never ulcerate and seldom suppurate, but may 
disintegrate and disappear, leaving pigmented scars, or, where 
they are in patches, the center only undergoes involution. This 
may occur in even a single nodule. On the trunk and face the 

p. 1, colored plate of the extremities. Hardaway, in vol. i. (1883), gives 
colored plate of face. 

*Sequeira, Brit. Jour. Derm., vol. xiii. (1901), p. 201, with colored 
plate. Histologically the growths were inflammatory and not sarcomata. 

\ Archiv f. Derm., etc., vol. xii. (18Q7), p. 163. colored plate. 

% Funk, loc. cit., gives many exceptional cases, and includes a very 
mild type. Kaposi, Besnier-Doyon edition, contains many references. 



°3° 



DISEASES OF THE SKIN. 



surface may be eroded and expose a blood-infiltrated tissue, 
which may become warty or fungoid from irritation. Dilated 
vessels and hemorrhages round the nodules are common. In 
middle-aged persons the general health may be but little af- 
fected for several years, except from the itching, burning, or 
pain in the extremities, but fresh nodules continue to form, and 
ultimately the mucous membranes are affected, when the down- 
hill course is often rapid. " Dark bluish-red patches, diffuse 
infiltrations, or little nodules arise on the gums, palate, or 
uvula; the tonsils become swollen, the patient becomes mark- 
edly anemic, emaciated, and feverish. The lymphatic glands, 
spleen, and liver become considerably enlarged. In this stage 
whole groups of nodules sometimes ulcerate, and deep, ichorous, 
extremely offensive ulcers are formed. The neoplasms of the 
mucous membranes ulcerate still more quickly " (Funk). 
Marasmus, bloody diarrhea, and hemoptysis close the scene, 
and post-mortem similar tumors are found in most of the vis- 
cera, especially in the descending colon, where they tend to 
slough. The ordinary duration is from three to five years, but 
in young persons death may occur in the first, second, or third 
year, while six or even twelve years may elapse in older people 
before the health gives way. Recovery does, however, occasion- 
ally take place. Hardaway's * and Funk's case recovered com- 
pletely. Mackenzie's case, which had previously been under 
Pringle, was a Galician Jew, set. forty-five, whom I had the 
opportunity of examining on several occasions. After present- 
ing all the typical symptoms, and having one leg amputated, he 
seemed to be in a hopeless condition, but ultimately, not appar- 
ently as the result of treatment, he improved, and when shown 
to the Dermatological Society in 1892, appeared to be in a fair 
way of recovery, large numbers of the tumors and the elephan- 
tiasis of the limbs having disappeared, and ultimately he got 
quite well, but with the hands permanently en griff e with much 
overextension at the knuckles, t In Jackson's case the fingers 
were permanently flexed on the palms. 

De Amicis, who has had even more cases than Kaposi, recog- 
nizes three stages: I. A period of infiltration forming plane 
maculae. II. A period of tumor formation with telangiectases, 

*Hardaway, Jour. Cut. and Gen.-Ur. Dz's., January, 1890. 
f Pringle, Photo. Club Atlas, 1898. 



SARCOMA CUTIS. 103 1 

angiomatous in character. III. A period of necrobiosis of the 
tumor and generalization. 

Etiology. — Most of the cases have occurred in middle-aged 
men, very few in women. A case of Kaposi's was seventy-three; 
several have occurred between twenty and thirty, and a few 
under twenty. Corlett (Cleveland, U. S.) had three cases in one 
family, the youngest two years old, and De Amicis had one of 
a child of five. A large proportion have been Polish and Ga- 
lician Jews of the lowest class; but whether this is the result 
of their race, their habits, or surroundings it is impossible to 
say. Its frequency in Naples suggests the latter. Jackson's 
case dated from a frost-bite, and Semenow regarded prolonged 
•exposure to cold as an important factor. 

Pathology. — Its pathology is quite unknown, but Fordyce and 
Wende advance plausible arguments in favor of its being caused 
by an infective agent. 

Anatomy. — Kaposi's and Stoukovenkoff's cases were chiefly small-celled 
growths which they called sarcoma, situated in the corium, riddled with 
-vascular sinuses and containing small hemorrhages, and free pigment 
granules, but Funk's, Schwimmer's, Fordyce's, and Jackson's cases were 
made up of spindle-cells closely interwoven, so that in cross-section they 
appear to be round cells. 

The pigment is entirely due to the hemorrhages, and therefore quite 
different from that of the other pigmented sarcomas. There are great 
numbers of new blood-vessels, numerous mitoses, and an intercellular 
reticulum. Pringle found bacilli in the tumors and sweat glands, but 
other observers have failed to do so. Semenow found changes in the 
peripheral nerves, and ascribes to them an etiopathological importance. 
De Amicis regards the disease as a granuloma; Sellei also takes this 
-view, which, though not established, is probably correct. 

Diagnosis. — The leading features are the commencement in 
the hands and feet of small painful plum-colored tumors, fol- 
lowed by elephantiasis, deformity of the extremities, board- 
like indurations, and ultimately generalization, with a usually 
fatal result. The diseases with which it may be confounded are 
at the commencement the palmar and plantar scaly syphilid, and 
later in its course mycosis fungoides, syphilitic gummata, and 
the nodules of lepra and lupus. 

Prognosis. — The majority of the cases have been fatal in from 
two to five years, but some have lived over twenty years (Bray- 
ton's twenty-five), and a few have recovered spontaneously, or 



1032 DISEASES OF THE SKIN. 

as the result of treatment (Hardaway's, Funk's, Mackenzie's,, 
Kobner's, and Pringle's). 

It has many features in common with Hutchinson's " sym- 
metrical purple congestion of the skin," and Sequeira regards 
the two affections as only variants of one disease. 

Treatment has been unavailing hitherto, but although it failed 
in Schwimmer's and Fordyce's cases, Kobner's * treatment by 
injections of liq. arsenicalis deserves further trial, as several have 
had encouraging improvement after its free administration. 

Sarcomatosis Cutis (Kaposi, third type). The following is 
from Kaposi's third American edition. The tumors may be 
very numerous on the trunk and limbs. They are bluish-red,, 
flat or somewhat prominent, in defined patches of the size of the 
finger-nail, which on palpation are firm elastic nodules deep in 
the corium and even below it. Earlier nodules can only be felt, 
not seen. Sometimes the nodules are painful, at others only 
tender. There are no glandular enlargement, no blood changes, 
or other general defect. Two men got quite well with " method- 
ical arsenic treatment." 

In a third case, an old woman, who had had the disease for 
four years, there were about one hundred tumors on the upper 
part of the trunk. The nodules were pea- to nut-sized, 
hemispherical, and firmly elastic; the small ones bright red, the 
larger bluish-red, smooth, shining, and tender. There were also 
some palm-sized flat raised plaques with a central depression 
and indented borders like the tomato form of mycosis fun- 
goides; there were another hundred nodules over the rest of 
the trunk and a few on the limbs. After seven or eight injec- 
tions of arseniate of soda, .02 gram every second day, the ma- 
jority of the nodules flattened and collapsed by half to two- 
thirds. Subsequently they continued to grow in spite of the 
arsenic; similar cases are on record, many cured by arsenic, but 
others fatal. Microscopically they were round-cell growths, 
sarcomata Kaposi called them, and different from lymphoma. 
Their greater depth in the cutis distinguishes them from mycosis 
fungoides. 

* Berlin med. Wochensch., 1883, No. 2. See p. 694. Abs. in Annates 
de Derm., vol. vii. (1886), p. 189. 



SARCOMA CUTIS. 



1033 



Joseph * brought before the Berlin Dermatological Society a 
man, 'set. thirty-two, on whom in a few months large numbers 
of tumors had developed over the whole body, including the 
scalp. They began in the dermis, and some were as large as 
a cherry; the skin over them was reddened from networks of 
dilated vessels; and the microscope showed that between the 
fibers of connective tissue there was an infiltration of round 
cells with vesicular nucleus and nucleolus. He regarded them 
as one of the cases of sarcoma cutis which Kaposi was the first 
to call sarcoid, belonging to his Type III. 

Multiple Benign Sarcoid (C. Boeckj.f The following is his 
summary of the characters of the disease after relating the 
cases. He also says a case was shown, but not recognized, at 
the Dermatological Congress in London in 1896. 

" The type case was a middle-aged, pale man, in whom were 
found groups of lymphatic glands much swollen, and on ex- 
amination a slight increase in the number of white corpuscles. 
At the same time there was a widespread, nearly symmetrical 
eruption of firm nodules on the head and extensor surfaces of 
the trunk and extremities. They ranged in size from a hemp 
seed to a bean, and the larger had irregular contours. They 
involved the whole skin and were movable with it. On the 
scalp there was no infiltration, but only yellowish patches. The 
color of the early nodules was bright red, becoming darker, and 
finally yellowish or brown. Slight scaling occurred on older 
lesions. They showed a tendency to peripheral spreading and 
central depression. On the face they had a peculiar appearance 
with blue center and yellow border — a feature present in all 
Boeck's cases. The nodules disappeared eventually, leaving, 
as a rule, a loss of substance in the skin, which was white on 
the face, yellow on the back, and darker at the periphery on 
the legs. Neither exudation nor ulceration ever took place. A 
papular eruption grouped like lichen planus was seen on the 
inside of the thighs. A tendency to develop on the site of an 

* Reported in Annates, vol. ix. (1898), p. 492. 

f C. Boeck, Amer. Jour. Cut. and Gen. -Ur. Dz's., vol. xvii. (1899), p. 543, 
with colored and photographic plates; also, " Weitere Beobachtungen 
liber das multiple benigne Sarcoid der Haut." Reprint from M. Kaposi's 
" Festschrift." 



1034 



DISEASES OF THE SKIN, 



old injury should be remembered. The symmetry was not such 
as is found in affections whose localization is evidently deter- 
mined by central nerve influence. The disease seemed to be 
benign, and disappeared under arsenic or perhaps spontane- 
ously. Compared with Mortimer's malady there were many 
points of resemblance; in the latter there are essentially the 
same symmetrical eruption of nodules and patches, in the same 
localities, a slow peripheral spreading with central depression, 
and after long duration, spontaneous involution without ulcera- 
tion and with loss of substance. 

" Hutchinson's cases had good health. He does not, how- 
ever, mention swelling of lymphatic glands nor the peculiar ap- 
pearance of the face patches. In his case there were diffuse 
subcutaneous infiltrations over the bridge of the nose and the 
ears. The nodules were, according to description and plates, 
more elevated than I have seen them. Future observation must 
decide to what degree these differences are essential." 

The histology was also unique. The areas of new growth 
might be described as perivascular sarcomatoid tissue, built up 
by excessively rapid proliferation of epithelioid connective tissue 
cells in the perivascular lymph spaces, with very few cells of 
other kinds. The tumor soon begins to degenerate, and the 
tissue is atrophied, showing a network of branched connective 
tissue cells. 

It should be remembered that true giant cells of sarcomatous 
type were found, though rarely. Compared with other new 
growths of the skin, this must be said histologically to possess 
affinity to sarcoma, and also to the very rare cases of so-called 
pseudo-leukemia cutis, described by Arning and Max Joseph. 
The new growths here described nevertheless seem at present 
to be rather sui generis. 

It should be particularly emphasized how different the his- 
tology of this process is from that of leukemia cutis with its 
lymphoid tissue and small lymphoid cells, but the clinical re- 
semblance is very close. 

Mortimer's Malady (Hutchinson's).* Hutchinson has met 
with four cases, two of them quite alike ; the other two " proba- 
bly allied." " The disease is characterized by the formation of 

* Hutchinson's Archives of Surgery, vol. ix., Plate CLII., p. 307. 



SARCOMA CUTIS. 



i°35 



multiple dusky red patches which have no tendency to inflame 
or ulcerate. They are very persistent, and extend but slowly. 
They occur in groups, and are usually on both sides and almost 
.symmetrical. 

" The multiplicity of the patches, their occurrence in groups, 
their bilateral symmetry, and the absence of all tendency to 
ulcerate or form crusts are features which separate the malady 
from lupus vulgaris." 

The type case was a woman, set. sixty-five, in whom the dis- 
ease had existed for a year in August, 1894. The lesions were 
in symmetrical groups on her face and upper arm. They were 
much raised, sharply defined, of dusky red color, and rather 
soft structure. Some had a slight exfoliative scaly crust, but 
with no ulceration beneath, and though some of the patches 
were depressed in the center there was no ulceration. Six 
months later the patches had increased in number and size, and 
many had coalesced on the left cheek and brow and the lobule 
of the left ear had become involved like common lupus. The 
nose was swollen across the bridge, forming a thick soft tumor, 
but without implicating the skin. Two years later the patches 
on the left cheek still showed their nodular origin. Many of 
the nodules were involuting, especially on the left eyebrow and 
ear; and on the arms some had quite disappeared and left thin 
scars. In 1897 her condition was nearly the same, and her 
general health had never been affected. 

His second case was a man of forty-five in whom it had been 
present several years on the face with very little change. His 
ears were much affected; there were large areas of scar with- 
out previous ulceration on the thighs and legs. 

There has been no histological investigation for comparison 
with Boeck's benign sarcoid (see that disease). The only case 
in my experience at all like it was a man with infiltration over 
the nose and ears, and round tumors with depressed centers, 
but it differed in that many of the lesions broke down and 
ulcerated. The pathology of Mortimer's malady therefore re- 
mains for future investigation. 



1036 DISEASES OF THE SKIN. 



LEUKEMIA CUTIS.* 



Biesiadecki in 1876 was the first to describe tumors in the 
skin along with the general symptoms of leukemia, anemia, 
enlarged spleen and lymphatic glands, increase of white corpus- 
cles, and eventually hemorrhages, etc. 

His case was a man of thirty in whom nodules from a millet 
seed to a lentil appeared in large numbers on the face and back; 
they were slightly raised, movable with the skin, flat, pale red, 
and smooth for the most part, but some were scaly and others 
depressed in the center and of lymphoid structure. 

Hochsinger and Schiff record a case of a boy of eight months 
with similar nodules all over the body, but especially on the 
head and face. In this case the nodules ranged up to the size 
of a hazelnut, and were yellowish- to brownish-red. 

Cases of this type have also been described by De Amicis, 
while Parvianovitch, Oliver, and Phillipert have reported cases 
of a different type, in association with leukemia. In Oliver's 
case, soon after a crushing injury to the metacarpal bone, hard 
nodules formed under the right supraclavicular fossa, and ulti- 
mately there were about sixty hard tumors from a bean to an 
egg scattered over the trunk, and an ulcerated egg-sized tumor 
in the axilla; the overlying epidermis was movable, but red- 
dened in the other tumors, some of which became soft. The 
white corpuscles were enormously increased. At the autopsy 
there were six orange-sized tumors in the enormous spleen. 
In Phillipert's case, which began on the temple in a woman, 
tumors of similar size formed in the head and face, the skin over 
them being smooth, glistening, and chestnut brown; and other 
tumors appeared on the mucous membrane of the nose, palate, 
and pharynx. There were nodules in the breast, but the rest 
of the skin was free; towards the end the color of the skin 
became like wax. and the tumors flat and shriveled. Leontiasis 
of the face was present in this and some other cases, e. g. r 
Gaillard's. 

* Liter at in- e. — A large number of references maybe found in Funk's 
" Clinical Studies of Sarcoma of the Skin," in " Rep. of the Second Inter. 
Cong, of Dermatology at Vienna," and Unna's " Histopathologv," p. 621. 
Also Nekam, " Ueber die leukaemischen Erkrankungen der Haut." L. 
Voss, Hamburg, 1899. 



LEUKEMIA CUTIS. 



1037 



Hallopeau and Laffite * have observed a case which was 
accompanied by eczematous and lichenoid lesions comparable 
to mycosis, and at a later period, diffuse thickening and redden- 
ing of the skin, exaggerating the normal elevations and depres- 
sions of the skin, but, unlike mycosis, diffusing gradually in to 
the healthy skin without forming tumors. The subcutaneous 
tissue was implicated, with induration, the surface was smooth 
and symmetrical. In their case the middle of the face was af- 
fected from the upper lip to the forehead, with great swelling 
and redness and exaggeration of the natural folds. 

In Neuberger's case there were' only two solitary brown tu- 
mors symmetrically placed on the cheeks, and they were lobu- 
lated, firm, and grew slowly for several years. 

A totally different type of case was described by Kaposi 
under the title of lymphodermia perniciosa. The disease began 
like a scalding, moist, and intensely itching eczema, and " gradu- 
ally resulted in diffuse soft swelling and thickening of the af- 
fected parts." 

Then cutaneous and subcutaneous, doughy or firm, in part 
ulcerating nodules developed, the glands and spleen enlarged, 
leukemia set in, and death ensued. There was general pallor 
of the skin and face, ears, forehead, lips, and integument of the 
thorax, and the arms exhibited shapeless nodular thickening. 
All the lesions of leukemia were found after death. This Vidal, 
Hallopeau, Paltauf, and myself regard as a variety of mycosis 
fungoides, a view which Kaposi himself admits is not improba- 
ble. The case I have described as Type III. of mycosis 
fungoides closely corresponds with Kaposi's in many respects 
except that the skin was red, not white, but unfortunately I 
was unable to examine the blood, nor was there any autopsy. 

Gaillard's case appears to be of this type, and one of De 
Amicis' cases was very like it, with enlarged glands, liver, and 
spleen, but no leukemia. In Riehl's case and one reported by 
Hallopeau and Laffite there was infiltration, but no tumor 
formation. In the latter case the infiltration was confined to the 
middle of the face. 

Kreibich has published yet another form of leukemia tumor 
from a case in Kaposi's clinic, f in which the tumors reached 

* Annales de Derm., vol. ix. (1899), P- 2 3&- 

\ Archiv. f. Derm. u. Syftk., vol. xix. (1899), P- 1S5, with colored plates 
and references; and Plate CLXXXVII., Kaposi's Hand Atlas. 



1038 DISEASES OF THE SKIN. 

the size of an apple, affecting the forehead, cheeks, chin, 
ears, and upper limbs, and subsequently some tumors as large 
as the fist were felt in the abdomen, the lekocytes were one 
to twenty-eight red, and the other symptoms of leukemia were 
present. The patient was a woman, set. sixty-three, and the first 
turners began as a red spot on the cheeks and took six months 
to develop into a tumor, but others had a more rapid course. 
The surface was smooth, reddish-violet, thinned, and could not 
be pinched up. Mayer's case in a man, set. sixty-eight, was of 
similar type. These, Oertel's, and Nekam's cases belong to 
what is called myelogenic leukemia. 

It will thus be seen that in association with leukemia there 
may be, (1) small nodules in the skin and subcutaneous tissue; 
(2) large tumors; and (3) a diffuse lymphatic thickening and 
hypertrophy of the integument, with enormously exaggerated 
folds producing leontiasis on the face, and followed sooner or 
later by the development of deep-seated convex tumors, the 
last corresponding to Type III. of mycosis fungoides. Leuko- 
cythemia is generally a late manifestation. 

Cases of diffuse thickening without tumors are probably of 
the same kind, only the case has not lived or been observed 
long enough for the supervention of the final tumor stage. 
Both these last forms are associated with some form of der- 
matitis, while in the others the surface of the skin even over 
the tumor is little, if at all, disturbed. 

In some cases the tumors have followed the leukemia, and 
in others preceded it; and with regard to the latter it may be 
a question whether the leukemia is not a consequence rather 
than a cause of the tumor formation. Thus in Palma's case, in 
which sarcoma of the thymus was found post-mortem, in life, 
the white corpuscles rose from 1 in 455 to 1 in 73 within a 
month. 

In nearly all the cases the tumors seem to commence as infil- 
trations between the cutis and subcutaneous layers, and en- 
croach upon both. 

According to Pincus,* the histological symptoms of leukemia 
skin tumors consist in a heaping up of lymphocytes in the 

* " Changes in the Skin in Leukemia and Pseudo-Leukemia." F. Pincus, 
Archiv f. Derm. u. Syfik., Band L. (1898), pp. 37 and 177, photographic 
plates. 



LEUKEMIA CUTIS. 



1039 



corium and subcutaneous lesions which grow in the tumors 
themselves from the traces of lymphatic tissues normally pres- 
ent (?), and they do not arise from the exudation of leukocytes 
from the blood current. There are also tumors of lymphatic 
granulation tissue. There is a possibility that the accumulation 
of lymphocytes may be due to diminished destruction, instead 
of increase of lymph cytes in the body. 

Oertel and Nekam say that the growths in both leukemia and 
pseudo-leukemia are formed from emigrant leukocytes, while 
the growths of lymphoma are metastatic. 

No special treatment for the tumors would be required, the 
general condition claiming all the attention. 

Chloroma. Green tumor is another form of neoplasm asso- 
ciated with lymphatic leukemia. In addition to the usual 
changes in the blood, bone marrow, lymphatic glands, spleen, 
and other organs, there are lymphoid deposits in the temporal 
fossae and periosteum of the bones of the skull and their ex- 
ternal and internal coverings. Further, there are green dis- 
colorations of the skin diffuse and in tumors which arise in the 
periosteum and spread by metastasis. Both Dunlop and Byrom 
Bramwell regard them as lympho-sarcomata, but the cause of 
the green color is unknown, but, as Dunlop has shown, it 
quickly disappears on exposure to air and in fluids which do 
not dissolve fat, thus negativing the theory of the green parti- 
cles being fatty bodies. There are only twenty-five indisputa- 
ble cases known, but Bramwell thinks there are similar cases 
without the green color which would enlarge the number con- 
siderably. 

Pseudo-Leukemia Cutis of German authors represents the 
skin changes observed in a few cases of Hodgkin's disease, and 
is what we should call lymphadenoma cutis. According to 
Joseph, who has had two cases, in one form, nodules both 
cutaneous and subcutaneous were distributed in large numbers 
on the neck and chest; they vary from a pea to a nut in size, 
project above the surface, but the epidermis over them is normal. 
They are movable, painful, and hard to the touch, and structur- 
ally consist of large and small round cells with bright nuclei and 
nucleoli; there are some fusiform elements and giant cells. 



1040 DISEASES OF THE SKIN. 

Lymphorrhea and death ensued shortly after removing some of 
the enlarged glands and skin tumors. These nodules resembled 
those of the first type described under leukemia. In the other 
form of which Arning,* Bowen, and Wagner, as well as Joseph, 
have each had examples, in addition to the tumors there were 
also intensely itching prurigo-like papules, and the general and 
skin symptoms were much ameliorated by arsenic. These 
papules f may also occur without the tumors. In neither form 
was there any increase in the white corpuscles of the blood, and 
the usual symptoms of Hodgkin's disease with enlarged glands 
and spleen were well marked. Gillot, Landouzy, and De Amicis 
have had similar cases. 

Arning has had another case which he refers to pseudo- 
leukemia, a girl, set. fourteen, who was sent to him for what 
was supposed to be lupus of the nose, but it had a waxy trans- 
parent look, was firm and painless, had never ulcerated, and 
there were no lupus nodules. 

She had also nodules on the mucosa of the lower lip and 
hard palate; and others in the skin of the face, neck, and upper 
extremities of varying size and consistency. No enlargement 
of glands or blood changes, but an immense spleen. Hypo- 
dermic injections of arsenic diminished the spleen to one-half, 
and the tumors also became smaller, some disappearing com- 
pletely. There were no prurigo-like papules, as in the previous 
cases. 

Other skin changes observed besides the prurigo papules are 
lichen papules (V. Recklinghausen) ; pityriasis rubra (Peter) ; 
desquamation in large lamellae with the skin pale yellowish 
(Wassermann). The last author also, in the same case, found 
the skin in certain points, especially on the face and legs, 
strongly retracted, atrophied, and shining, very adherent to the 
subjacent tissues, and feeling like parchment; also some linese 
atrophica?. I have also had a case in which severe pruritus in 
the legs and feet was one of the early symptoms, when there 
were only a few cervical glands enlarged, and as there was a 
strong family history of phthisis they were diagnosed as tu- 
berculous. Subsequently all the symptoms of Hodgkin de- 
veloped and pea-sized pruritic nodules appeared. Hallo- 

* Abs. Brit. Jour. Derm., vol. iv. (1892), p. 295. 

f Bowen says that they have the same structure as true prurigo papules. 



LEUKEMIA CUTIS. 



1041 



peau and Laffite have also noted pruritis without other skin 
lesions. 

According to Pincus (Joe. cit.), the tumorlike formations oc- 
curring in lymphatic leukemia are not to be distinguished from 
those of pseudo-leukemia. The skin localizations are clinically 
and histologically identical, the general affections also cannot 
be distinguished by constant clinical differences in the blood; 
while qualitative blood conditions and all the other symptoms 
and the pathological anatomy are identical. Therefore these 
cases form one group to be contrasted with myelogenic leuke- 
mia, i. e., cases in which myelocytes can be found in the blood. 
Wende's * case rather supports this, but he regards it as an 
instance of conversion of Hodgkin's disease into leukemia. A 
man, set. twenty-six, was first seen on April 26, 1900, who stated 
that on December 1, 1899, he first noticed a slight induration 
on the left temple, which by April was an oval dusky pro- 
tuberance 10 cm. across and non-adherent. There was also a 
deep-seated induration in the center of the left cheek. There 
was marked enlargement of glands, but very slight blood 
changes. 

In the left inframammary region were two lumps the size 
of a filbert, and round the nipple there was a large patch like 
that on the temple, while in the abdominal wall were seven deep- 
seated nodules from a pea to a hickory-nut in size, the largest 
of which was cyanotic and brown. Chocolate-colored blotches 
mottled the whole chest and back, and all the superficial cervical 
glands were enlarged, especially on the left side. 

Temporary improvement was produced by the injection of 
Fowler's solution, so that all lesions except the staining had 
disappeared in six weeks. 

On July 1 a tumor appeared suddenly on the scalp, followed 
by two on the back. A few days later extensive purpura super- 
vened, and there was enlarged spleen, leukemia 34,000 to the 
cubic millimeter, swelling of mucous membranes and death on 
July 30. The cutaneous lesions consisted of lymphoid cells go- 
ing down to the subcutaneous tissue. 

Unna \ describes these tumors as " a form of granuloma 

* Amer. Jour, of Med. Sciences, December, 1901. Abs. Lancet, March 
15, 1902, p. 752. 

f " Histopathology," p. 621. 
66 



1042 DISEASES OF THE SKIN. 

closely resembling lupus and the tuberous syphilids." Graham 
Little * agrees with this, and the examination of some small 
yellowish growths, of which there were hundreds, showed 
deep-cell infiltration most abundant in the middle zones of the 
cutis, and especially affecting, as also noted by Arning, the 
sweat coils. The cells were what he calls " daughter plasma- 
cells." Mast cells also were abundant, but there were no giant 
cells. 

Pincus wishes to separate mycosis erythrodermia from my- 
cosis fungoides and join it with Kaposi's lymphodermia 
perniciosa into a special group with the symptoms of (i) ery- 
throdermia; (2) diffuse thickening of the skin as seen in leonti- 
asis of the face; and (3) by co-existing leukocythemia, which 
is usually a late symptom, but I do not agree with this view. 

Treatment. — Arsenic injections offer the only chance of ameli- 
oration, and Touton and Zeisler have had cures from this 
method. The formula given by Johnston is 7 cgm. of cacodylate 
of sodium, 2 cgm. sodium arsenite, water, and Fowler's solu- 
tion, of each 5 drops, increased gradually to toleration. Such 
doses would only be justifiable in desperate cases. 

MYCOSIS FUNGOIDES. t 

Deriv. — jAVHrfS, a fungus. 
Synonyms. — Granuloma fungoides (Auspitz, Payne, and others); 
Eczema hypertrophicum or tuberosum (Wilson); Inflam- 
matory fungoid neoplasm (Geber and Duhring); Fibroma, 
fungoides (Tilbury Fox); Ulcerative scrofuloderma (Van 
Harlingen); Lymphadenie cutanee; Lymphodermia perni- 
ciosa (Kaposi); Sarcomatosis generalis (Kaposi); Multiple 
sarcoma of skin (Nevins Hyde); Multiple fungoid papillo- 
matous tumors (Kobner); Lichen hypertrophique (Hardy). 
(Hardy). 

Alibert, in his great work of 1814, first described and figured 
in Plate XXXVI. a case of this disease in a Parisian, under the 
name of " pian fungoide," which he regarded as allied to yaws, 

* Brit. Jour. Derm., vol. xiv., June, 1902, r>. 217. 

\ Literature.— Author's Atlas, Plate LXXVIII. St. Louis Atlas, Plates 
XIV. and XVI. Vidal and Brocq, " Mycosis f on goide." La France 
Medicate, Nos. 78 to 85, tome ii., 1885, gives a full account, with bibli- 



MYCOSIS FUNGOIDES. 



io-k 



and identical with Amboyna button, or pian of the Moluccas; 
in his 1832 8vo and 4to editions, he changed the name to 
mycosis, referring to its external resemblance to a mushroom, 
and not to a theory of its pathology. Bazin in 1862 was the 
first to give a clear account of the disease. 

That Alibert was not far wrong as to its clinical resemblance 
to yaws is shown by the fact that so great an authority on yaws 
as Gavin Milroy * relates a case, which is clearly the disease 
under consideration, as an example of yaws in a man who had 
never resided out of England. Subsequent French writers, 
especially Bazin, Hardy, Besnier, Vidal, Brocq, and Hallopeau, 
have made our clinical knowledge of the disease pretty com- 
plete. Isolated cases have from time to time been reported 
under various names, of which some are given above. English, 
German, and American authors now acknowledge their identity 
with Alibert's disease. In England, of late years, many cases 
have been shown at the Dermatological Society. 

The cases may be divided into three distinct classes or types. 

In Type L, which is the most common, there is some form 
of dermatitis antecedent to the development of tumors, the 
premycosic stage of French authors. 

ography to date. Auspitz, "Granuloma Fungoides," Viertelj.f. Derm, 
u. Syph., vol. xii. (1885), p. 123, with colored plates, and Hochsinger n. 
Schiff, in vol. xiii. (1886), pp. 361, 389. Payne, " Granuloma Fungoides." 
Path. Trans., vol. xxvii. (1886), p. 22, with colored plates and partial bibli- 
ography. Tilden, " Mycosis Fungoides," Boston Med. and Surg. Jour. , 
October 22, 1885, p. 386 — a good account and full bibliography. Funk, 
loc. cit., see Sarcoma. Ledermann, two cases. Archiv f. Der?n. u. Syph., 
vol. xxi. (1889) p. 683, gives full bibliography. Stelwagon and J. L. 
Hatch, "A Study of Mycosis Fungoides," with a report of two cases; 
the histology and bacteriology were thoroughly gone into, and the bibli- 
ography from 1885 given, but Hallopeau's case, alluded to, turned out to 
be general lupus erythematosus. Besnier, "A Contribution to the 
Clinical History of Mycosis Fungoides, especially of the Pre-mycosic 
Period," with two new cases, Jour, des Maladies Cutanees, vol. iv. (1892); 
and Ann. de Derm, et de Syph., vol. iii. (1892), pp. 242 and 987, with 
Hallopeau. Hallopeau has published several cases with interesting 
features in the Ann. de Derm, et de Syph., vol. iv. (1893), to vol. ix. (1898), 
and Besnier and Hallopeau read a paper on Erythrodermia premycosique 
at the Vienna Dermatological Congress, 1893, when there was also a dis- 
cussion on the lymphangitis form. " Mycosis Fungoides," a monograph 
by Max Wolters : " Biblioth. Med. Abth.D. n Derm. u. Syph.," 1899, with 
bibliography and plates. 

* Med. Times and Gazette, February 17, 1877, p. 169. 



1044 DISEASES OF THE SKIN. 

In Type II. the course is marked by recurrent attacks of 
lymphangitis leading to an elephantiasic form of thickening of 
the skin, with tumor development for the final stage. This is 
the rarest form. 

In Type III. the tumors develop without antecedent derma- 
titis, the " tumeurs d'emblee " of French authors, and the course 
is shortened. 

All forms are fatal, but the premycosic stage of Type I. may 
last for many years. 

Mycosic fungoides is fortunately a rare disease, but thirteen 
cases of it have occurred in my private and public practice in 
the last few years, and I have seen many others at the societies 
and elsewhere. Seven of my cases were of Type I., one of 
Type II., and five of Type III. 

In Type I. the antecedent dermatitis is of the most variable 
description, but whether all cases are mycosis fungoides from 
the first, and what appears to be an ordinary dermatitis is only 
simulated, is a disputed point. At all events, some cases are 
recognizable as mycosis fungoides from the first, while others 
are not so until the tumor stage is reached. Probably the most 
common form of eruption is of an erythematous character, the 
" erythrodermia " of Besnier; in it there are erythematous discs 
slightly raised at the border and firm to the touch, or there may 
be red urticaria-like lesions, which Kaposi says do not itch, but 
this is not true for all cases. These extend into diffuse infiltra- 
tions and assume a brownish tint, and when on the face closely 
simulate lepra, as in a case shown to me by Stephen Mackenzie. 
Duhring's case began with acute urticaria, then developed a 
universal vesicular eruption which lasted a week, severe pruritus 
followed, and in six weeks from the onset the first tumor ap- 
peared. Almost equally common is the development of a moist 
or dry eczema; * the case of Fig. 2 of my Atlas which was under 
Colcott Fox's care was described by him as like " inveterate 
scaly eczema," while Lukasiewicz described his case as an 
" eczema rubrum madidans." 

In one of my cases, when I saw him shortly before the de- 
velopment of the tumors, the eruption appeared absolutely indis- 

* At a discussion at the Amer. Derm. Assoc, many disputed the eruption 
being really like eczema, but so many good observers from Hebra down- 
ward have so described it that it must be true for some cases. 



MYCOSIS FUXGOIDES. 



045 



tinguishable from pityriasis rubra, and it had been so for three 
years; he had been subject to psoriasis for twenty years and for 
the last eight years without intermission. Orange-red plaques, 
which gradually increased in number, size, and later on in 
thickness, marked the onset of another case which was fatal 
in six years. 

In two of my cases, both ladies, there was an eruption which 
at first sight was psoriasiform, but which was really a distinctive 
eruption. This form occurs in flat, well-defined discs of a pale 
red color covered with fine scales, rather scanty on the central 
part, but more marked and slightly crusted on the well-defined 
border. 

These discs coalesce and inclose oases of healthy skin, look- 
ing depressed in contrast with the prominent border of the dis- 
eased surface, recalling, except for the scaliness, the appearance 
often seen in the early stage of nodulated leprosy. Subse- 
quently in this, as in the other form of premycosic dermatitis, 
the affected part becomes thickened and infiltrated, and from 
this tumors form. Hallopeau and Bureau describe a case with 
this form of eruption; and Hallopeau and Jeanselme also had 
a case in which the first eruption was scarlatiniform, followed by 
large flaky desquamation. All forms of premycosic dermatitis 
are attended with pricking, burning, and itching, usually severe, 
sometimes moderate, but rarely absent. 

I have, however, met with three cases, all remarkably alike, 
in which there was no itching or any other subjective symptom. 
One was a man of thirty, in whom the eruption had been pres- 
ent for ten years, and while fresh lesions appeared from time 
to time, none had gone away in spite of the most varied treat- 
ment. The eruption was general, but on the trunk the lesions 
were thickly placed in horizontal, elongated, faintly rough 
patches, one to three inches long, as if streaked with the finger; 
pale red, almost yellowish in tint, rather well defined, though 
the edges were not sharp, and there was slight tnickening. The 
patient was a healthy man and no etiological factor was ascer- 
tainable. 

In a second case, a man of thirty-seven, the eruption had been 
present five years, and was limited to the limbs. 

In a third, a lady of forty-seven, the eruption had been present 
nearly ten years. It began as a single patch on the arm, and 



1046 DISEASES OF THE SKIN. 

spread all over the body from that. The patches were ill de- 
fined and pale red with slight powdery roughness, and some 
were decidedly thickened. They died down to some extent in 
the summer and recrudesced in the winter, when it smarted but 
never itched. 

Sometimes the erythematous lesions continue to develop after 
the tumor stage is reached, and I saw a case in which tumors 
on the face appeared first, and soon after erythematous discs 
formed on the upper limbs. 

This premycosic period may last for months or years, the 
disease remaining quite superficial; then it gets deep, involves 
the whole thickness of the skin, which becomes infiltrated and 
stiff, from a sort of hard edema like that of leprosy; but the 
redness pari passu increases, and the papillary body thickens 
into papules or plaques, forming the lichenoid plaques of Bazin. 
These may disappear rather rapidly, but soon re-form on the 
same or different parts; or they may develop more and more 
above the surface till they constitute true tumors, and bullae 
sometimes develop on and round the extending infiltrations; 
occasionally, the tumors form on the healthy skin as well, and 
in one of Stelwagon's cases the tumors developed almost simul- 
taneously with the erythema, an eruption, which appeared to 
be erysipelas, being the immediate antecedent where the tu- 
mors were about to appear. 

The tumors which mark the third stage of the malady may 
commence in or involve any part of the body surface, including 
the mucous membranes, especially the uvula and palate, but the 
larynx (De H. Hall), the pharynx (Besnier), and the bladder 
(Duhring) have been attacked. The viscera almost always 
escape even at the end, though a nodule on a kidney was ob- 
served by Hallopeau in one case. Crull also found a nodule 
in one kidney and in the lung. Pye-Smith found one adrenal 
converted into what looked like a round-celled sarcoma. 

In one of Kaposi's cases, nodules were found in various vis- 
cera; and in one reported by Malherbe and Monnier * a woman 
of thirty-eight, who died in two years, there were tumors in 
the lungs, the heart, the kidneys, uterus, both ovaries, and the 
pancreas. There were also tumors in the breast, but the diag- 
nosis is not indisputable. 

* Jour. Mai. Cut., vol. xii. (1900), p. 307, abs. 



MYCOSIS FUNGOIDES. 1047 

The skin tumors are of a bright, deep brownish, or bluish-red, 
rarely pale or yellowish-white, rather sharply defined, roundish 
or oval, at first merely convex projections, but soon becoming 
more elevated and sometimes slightly pedicled, and from a 
lentil to the fist in size. The large ones, from confluence, are 
covered with tense, shining epidermis, or they may be scaly or 
slightly crusted with horny epidermis. 

They may disappear in the course of a few days, without 
ulceration, and leave no trace; but more frequently they ulcerate 
very gradually, the epidermis falling off, and excavations or 
abscesses may be formed in them. By this time " the fungoid 
state " is reached, in which variously-sized, fungating tumors 
are developed. 

A characteristic formation is that of a round horseshoe- 
shaped or crescentic ulcer with a raised rolled border, a quarter 
of an inch wide in a big one, forming a collar from which the 
central fungating mass projects sometimes bright red, but more 
frequently with a sloughy covering. Even at this stage the 
tumor sometimes sloughs out and heals up, but more frequently 
extension takes place, the collar and central portion enlarging 
pari passu. There is always more or less sloughing in some of 
the tumors, but in a case of Hallopeau's massive gangrene of 
the scalp occurred, exposing the skull. 

In the tumor stage sensibility is diminished, and pain, itch- 
ing, and smarting have disappeared almost entirely in many 
cases, but sometimes the itching persists. The lymphatic glands 
generally may be enlarged. In hairy parts the hair falls off over 
the tumors and eruptions, which may be seen simultaneously on 
the same patient. The general health is but little changed, but 
after a variable time cachexia sets in, with rapid emaciation, 
and often obstinate diarrhea or pulmonary complications usher 
in the end. According to Sabouraud and Leredde, death is 
nearly always due to streptococcal infection. In one of my 
cases * there was a boardlike infiltration extending over one side 
of the neck, which at the autopsy Pernet found to be the solid, 
uniform infiltration without pus which is characteristic of this 
form of streptococcal infection. 

The total duration varies from six months to five or even 
fifteen years. Bazin records a case of complete recovery, the 
* Lovelace, U. C. H. 



1048 DISEASES OF THE SKIN. 

tumors having rapidly and permanently disappeared after an 
attack of erysipelas. Funk regards this case as an example of 
idiopathic multiple hemorrhagic sarcoma. In a case which I 
only saw in the premycosic stage, but in which the diagnosis was 
made independently by G. H. Fox of New York as well, after 
the patches had become greatly raised, and a tumor the size 
of an egg had formed behind the knee, she got well in a month 
under a course of purgation. 

Type II. is well represented in the following case. A doctor, 
set. forty-eight, had a kick on the knee, followed by suppura-' 
tion over the head of the tibia, and in the groin and thigh. 
Six or seven months from the onset he had lymphangitis in the 
groin, which was called erysipelas. A year later his skin was 
first attacked, beginning on the chest and gradually extending. 
In its early stage the eruption consisted of round millet-seed- 
sized, red papules seated at the hair follicles and slightly flat- 
tened at the top, and there was a minute horny spine in the 




Fig. 61. — A portion of a mycosis fungoides tumor highly magnified. 

The cells are imbedded in a delicate fibrous stroma. Obj. | P. and L., 

ocul. 2-in. 

center in those on the neck and on the back, and a slight rough- 
ness in the rest. At first they were closely aggregated, and 
developed into patches later. The papules coalesced and 
formed a diffuse brick-red erythema, with infiltration of the 
skin extending all over the trunk, face, and neck, and upper 
part of the limbs. It was attended with great irritation at night, 
but only on exposure in the daytime. There was a dry, pow- 
dery scaliness round the hair on the face, and many of the hairs 
broke off, and occasionally he had scattered pustular follicu- 
litis. The skin of the brows was thickened and corrugated like 



MYCOSIS FUXGOIDES. 1049 

that of a leper, but the color was bright red, and this condition 
was much increased after an attack of influenza, when the whole 
skin except the lower segments of the limbs was like that of 
a boiled lobster, but smoother than it had been. 

From time to time localized swellings appeared in various 
parts of the body and subsided in from three to six days. 
Every two or three months, also, he had attacks of lymphan- 
gitis, preceded by an intensification of the itching and pain of 
the following kind. Intense pain under the lower third of the 
left thigh came on suddenly in the night; after two hours the 
pain became less intense, and the lymphatics of the limb became 
cordlike; the redness and intense tenderness all round the thigh 
lasted forty-eight hours, and gradually subsided after applying 
a hot-water bag. He had also several attacks of what he called 
acute weeping eczema, especially of the head, feet, and face. 
The attacks of lymphangitis naturally increased the infiltration, 
which was especially noticeable on the face and ears. About 
a month before the end the face was enormously swollen and 
unrecognizable, the furrows obliterated, all the hair w T as lost, 
and the scalp swollen, so that the head and face were like a huge 
globe, the lobes of the ears were as big as walnuts, and the 
rest of them much swollen but not misshapen. On the scalp 
were numerous growths in the shape of convex eminences 
which had been developing about six weeks, and were deep 
in the cutis or subcutaneous tissue, and the whole of the upper 
part of the chest was covered by similar but more distinctly 
convex tumors, closely aggregated all over, although they had 
only been noticed for a fortnight. There were similar but less 
numerous growths in the upper part of the trunk, but none on 
the rest of the body. All these symptoms increased to within 
a few days of his death, when some of the s veiling subsided, 
and although the tumors extended to the epigastrium, they re- 
mained deep in the cutis and never broke down. 

Kaposi, under the title of lymphodermia perniciosa, described 
a similar case in 1885, but there was pallor of the surface, great 
increase of white and diminution of red blood corpuscles, with 
enlargement of the spleen and lymphatic glands. (See Leu- 
kemia Cutis.) Hallopeau's " red man " seemed to have com- 
menced like my patient, and a similar swelling of the features 
occurred in Jamieson's case. 



1050 DISEASES OF THE SKIN. 

In J. Hutchinson, Jr.'s, * case of hypertrophic swelling of the 
face, body, and limbs, the skin was in thick folds as if it were 
too big for its owner, following repeated attacks of erysipela- 
toid lymphangitis; all the nails and hair were shed, and the 
glands enlarged, but there was no leukemia; no tumors devel- 
oped before death. Hallopeau had a similar case. 

In Type III. of my five cases, in one, a man of fine physique, 
set. thirty-three, the first symptom was a tumor the size of a 
walnut, which appeared in the abdominal wall without any ante- 
cedent lesions, and rapidly increased to the size of an orange, 
oozed a green fluid, was poulticed and sloughed out. Soon 
after this he had red spots half an inch in diameter, which lasted 
a fortnight; three months later a tumor developed on the hard 
palate, which later on also sloughed out. From time to time 
tumors appeared and disappeared, and at one time he shed all 
his finger-nails and nearly all his hair; and after a severe attack 
of pneumonia with high temperature all the tumors went, leav- 
ing only a few healing ulcers. He was nearly well for some 
time after this, but never quite free from sores; subsequently 
tumors redeveloped, he had epileptiform convulsions, symp- 
toms of thrombosis in the cerebral vessels, and he died three 
and a half years from the onset. 

Most of the tumours d'emblcc type run a much shorter course 
than this, as in my second case. A man, set. sixty-five, first 
noticed finger-tip red spots on his forehead three months before 
I saw him; they got larger, more prominently convex, a deep 
dusky red, and a slight scaly crust formed on some of them, due 
to plugs in the sebaceous orifices; the rest were smooth. One 
on the right temple developed more rapidly, and broke down 
when it was five weeks old, and formed a fungating tumor one 
and a half inch in diameter, arising out of a projecting red 
rounded collar or ring about a fifth of an inch thick. Another 
tumor on the thigh was as large as a hen's egg, and had not 
ulcerated; it was excised, and, as usual, did not return. 

There were numerous other tumors or infiltrated patches over 
the trunk and face in various stages, and the fungating tumors 
continued to develop as a whole, although many of the growths 
in the pre-ulcerative stage involuted under treatment. The 

* Brit. four. Derm., vol. vii. (1895), p. 1, illustrated; and Jamieson's, 
in Edm. Med. Jour., March, 1893, also illustrated. 



MYCOSIS FUNGOIDES. 105 i 

right temple tumor became a fungating growth several inches in 
diameter, with sloughing center, and numerous others on the 
face were broken down, and he died exhausted in five months 
from the onset. There was no visceral complication. 

In a third case the tumors commenced in the groin and fore- 
head at the age of thirty-six, and became in six months very 
numerous on the face and limbs, but very few came on the 
trunk. They were about three-quarters of an inch in diameter, 
like half a cherry, were slightly crusted, but not ulcerated. 
The patient did not wait for the denouement, but in despair com- 
mitted suicide. He was a tall, vigorous man, and as there was 
a history of syphilis, he had had strong anti-syphilitic treatment 
without effect on the lesions. 

In the second case the mode of development in the neoplasms 
could be traced in different stages on the body. 

The first lesions were papules closely aggregated into small 
patches; the papules were pale red, pin's-point- to pin's-head- 
sized, with a central horny punctum; here and there there was 
partial coalescence, and the larger papules had two or three 
horny puncta. In the next stage the papules enlarged periph- 
erally, flattened out somewhat, and were semi-coalescent in the 
central portion, and had acquired a deeper red tint, while still 
discrete and pale at the periphery. 

Next the coalescence became more complete, and at the 
center formed an infiltration, in which the components were still 
indicated by fine lines, and finally the whole patch was a uni- 
form infiltration, but still with the shallow sulci dividing it. 

The tumors were a further development from these. 

According to Hallopeau the lymphatic glands are not en- 
larged in the tumeurs d'emblce type, and were not markedly so 
in my cases. 

In a case of Dubreuilh's the first growth appeared in the 
upper eyelid of a man of forty-four, other tumors followed on 
the face and axillae, and three months from the onset urticarial 
patches appeared with itching, and from that time formed part 
of the disease. 

Etiology. — Very little is known under this head. Tilden's, 
Hyde and Montgomery's, and my own analyses show that two- 
thirds of the cases are of the male sex. Three-quarters of the 
patients are over thirty years old, from forty to fifty and fifty 



1052 



DISEASES OF THE SKIN. 



to sixty being the most common decades, the extremes being 
fifteen (Gastou and Sabareanu) and seventy-three years (Hallo- 
peau). I have met with one which began at eighteen. No two 
instances have occurred in the same family, and, unlike yaws, 
it is not contagious. 

Pernet has noted th^t a large number of the patients come 
of a long-lived family, and they are generally in good health 
when attacked and for a long time afterwards. Although many 
of the cases with dermatitis antecedent to the tumors are un- 
doubtedly mycosis fungoides from the onset, the evidence is 
in favor of the disease developing in some instances on an ordi- 
nary dermatitis. One of my cases was certainly subject to ordi- 
nary psoriasis for many years, and was indistinguishable from 
ordinary exfoliating dermatitis for three years before the onset 
of the tumors, and there are many similar instances; but Bes- 
nier and other high authorities think they are all mycosis 
fungoides from the very first, and that microscopic examina- 
tion would prove it. Besnier also thinks that the tumors never 
start from quite healthy skin, but in one of my cases they cer- 
tainly did so. 

Pathology. — The preponderance of opinion, and the fact that 
partial improvement may be obtained in some cases by arsenic 
and salicin, suggest that the morbid phenomena are the result 
of bacterial action, either directly or through their toxin, al- 
though the organism has not yet been identified. The growths 
therefore belong to granuloma, and not to sarcoma, lympho- 
sarcoma, or lymphadenoma, as some of the earlier writers have 
suggested. Anatomically the tumors consist of round cells sup- 
ported by a scanty delicate reticulum, which replace the normal 
tissue of the cutis, the boundary between the healthy and dis- 
eased tissues being ill defined. 

Anatomy. — The histology has been investigated by a host of observers, 
but only those made by modern methods will be considered. Of these 
Unna, Leredde, Hyde and Montgomery, Galloway and Macleod,* appear 
to me of most value. They all advocate the diagnostic importance of 
biopsy in an early stage. 

Leredde has examined in the premycosic stage apparently healthy skin 

*Unna, " Histopathology," p. 509. Leredde, Annates de Derm, et de 
Sypk., 1894, p. 509. Hyde and Montgomery, Trans. Amer. Derm, Assoc, 
1898, p. 42; a good review of previous observations and references. 
Galloway and Macleod, Brit. Jour. Derm., vol. xi. (1900). May and June. 



MYCOSIS FUNGOIDES. 1053 

and erythematous plaques, and has found changes in the shape of pro- 
liferation of fixed cells round the vessels; mast-cells; perivascular foci, 
consisting of a reticulum including fixed and lymphocyte cells; the foci 
form in the subpapiliary layer and invade the papilla? at a later stage; 
there are vascular changes with a special type of giant cells. 

Unna lays great stress on the multiformity of the cells, which is con- 
firmed by others. He examined a case of the seborrheic eczemaform 
type in which, therefore, the epidermic changes were conspicuous. He 
regards it as a mixed infection with seborrheic catarrh, but this view is 
not generally accepted. 

Hyde and Montgomery regard the disease as sui generis from the 
earliest pruritic symptoms, differing from infectious granulomata, in that 
its manifestations are limited to the skin with a few doubtful exceptions. 

Vollmer thinks that in addition to the connective tissue cell changes 
those in the epithelium, edema of stratum granulosena, etc., are also 
characteristic. 

Galloway and Macleod, from the examination of three cases, find the 
following: 

A. In the premycosic stage. 1. A connective tissue cell proliferation 
around the blood-vessels of the whole corium and the structures in it, 
commencing in the subpapiliary layer. In the early stage the infiltra- 
tion is on the upper part of the corium only. 2. These cells are of five 
types — {a) Large, oval, fusiform, or roundish, with a large nucleus, with 
mitotic figures in the early, but amitotic in the late stage; (b) Small round 
cells a little larger than leukocytes, with nuclei like a ; they were the 
products of the rapid amitotic division of a ; (c) Mast cells, but not 
in increased numbers, and varying in size from a to b ; (d) A few 
plasma cells of the larger variety; (<?) Imperfect giant cells, with eight to 
ten nuclei, were sometimes seen. It is evident that a and b are numeri- 
cally the most important elements. The epidermic changes were 
secondary, and showed active mitosis of the prickle cells and downgrowth 
of the interpapillary spaces. 

B. In the tumor and breaking-down stage, there was increased cell 
proliferation, with tendency to break down very marked in the fungating 
stage, while the granuloma encroached on the epidermis, flattening and 
destroying up to the stratum corneum. 

Bacteriological investigation yielded no practical result, and they could 
not find McVail's * "short white bacillus." They differentiate micro- 
scopically other granulomata as follows: 

In syphilis the cell proliferation is less multiform, plasma cells are more 
numerous, the vessels more dilated, and the cell proliferation round them 
is at its maximum and the collagen is increased. 

In mycosis multiformity in the cells is characteristic, plasma cells are 
rare, cell proliferation round the vessels moderate. In the later stage the 
crenation and fragmentation of the cells is a distinguishing feature. 

In tuberculosis the granuloma is almost made up of plasma and its 

*Abs. McVail and W. D. Murray's case in Brit. Jour. Derm., vol. x. 
(1S99), p. 169. The bacteriology appears to have been carefully done. 



1054 DISEASES OF THE SKIN. 

daughter cells. There are giant cells with central caseous degeneration 
which are never present in mycosis. The collagen bundles disappear in 
an early, while in mycosis they only go in a late, stage. 

In round-celled sarcoma the mesoblastic cells are uniform in size and 
shape. The deeper layers of the cutis are first affected, and the epidermis 
not at all unless the sarcoma breaks down. In the spindle-celled form, 
also the cells are more uniform and rarely show karyokinetic figures. 

In leukemia cutis, the infiltration is purely leukocytic, there is no fixed 
cell proliferation, mitosis, or imperfect giant cell formation. 

Diagnosis. — At the beginning, when apparently simple erup- 
tions precede the formation of the tumors, the diagnosis may 
be very difficult, even Hebra having once diagnosed a case as 
eczema, and it may also be mistaken for erythema exudativum, 
psoriasis, pityriasis rubra, some form of lichen, or even nodu- 
lated leprosy. 

The irregularity of distribution, the sharply defined border,, 
and the greater thickening, which is more than in erythema, 
eczema, or psoriasis, might excite suspicion. 

The oases of healthy skin appearing depressed by contrast 
with the raised diseased areas inclosing them are very sug- 
gestive. 

There is generally not so much discharge as in eczema, with 
the same amount of hyperemia; not the heaping of silvery 
scales of psoriasis, neither is it in the psoriasis positions; while 
it is too chronic for erythema exudativum when it is smooth, and 
very often there is too much scaliness. 

The cases which imitate pityriasis rubra may be indistin- 
guishable, except histologically, until thickening of the tissues 
occurs. The licheniform cases do not exactly imitate the recog- 
nized forms of lichen; even when the papules are flat, they are 
not angular, and of the color of lichen planus. 

In the leprosy-like cases the resemblance is limited to the 
face, and there would not be the leprosy nodules, the general 
or nerve symptoms, and the leprosy bacilli, and in many cases 
the patient would not have been in a leprosy district; and al- 
though on the body, similar oases of healthy skin are often 
seen in the early stage of leprosy, the surrounding leprotic 
infiltration is not scaly, but a dull red or brownish erythema 
quite unlike that of mycosis fungoides. 

The itching, too, is generally more severe than it would be 
in all but eczema, and enlargement of the lymphatic glands is 



MYCOSIS FUXGOIDES. 1055 

general and pronounced without leukemia. Finally, Besnier 
says, " In all cases of ambiguous pruritic dermatoses which are 
prolonged and rebellious to ordinary methods of treatment, the 
possibility of the disease being the premycosic period of mycosis 
fungoides should be borne in mind." 

In doubtful cases, wherever possible, a piece of skin should 
be excised and examined microscopically. 

The lymphangitic cases, which soon develop into general red- 
ness and thickening of the tissues, llxommc rouge of French au- 
thors, are very distinctive, even before the enormous hyper- 
trophy occurs which brings the skin in thick folds. 

The tumor development is often a late feature, and there may 
never be fungation, as the tumors are more deeply seated as 
a rule. The enlarged spleen and glands and the blood changes 
are confirmatory. 

When the fungating tumor stage is reached there can be no 
difficulty. In the more localized forms, where there is no pre- 
ceding eruption, it may be mistaken for sarcoma or carcinoma 
cutis; the absence of early implication of the lymphatic glands, 
although tumors in the groin may simulate them, and the com- 
parative painlessness would perhaps be a help to a right con- 
clusion, while, as a rule, the course would be slower, and the 
internal organs would never be implicated. 

It would help if proof could be obtained in sarcoma that it 
started from a deeper structure. Further, it is rare for sar- 
comata to disappear spontaneously, while it is a common fea- 
ture of mycosis fungoides. 

Prognosis. — With the exception of Bazin's and Geber's cases, 
and one of my own, the result has invariably been fatal, the 
extremes being nine weeks (Gaillard) and twenty years, the 
widespread cases, which commence as apparently simple inflam- 
mations, being much less malignant in their course than the 
cases which begin at once as tumors. With this exception we 
have no data to guide us as to the course the disease will take. 

Treatment. — Nothing has, unfortunately, appeared to exert 
any influence in stopping the course of the disease, and we are 
so completely at sea as to its true etiology and pathology that 
the therapeutics must be entirely empirical. 

Arsenic has, of course, been tried most extensively. Stel- 
wagon tried arsenic internally and by subcutaneous injection 



1056 DISEASES OF THE SKIN. 

most thoroughly in one case, but with no good result; never- 
theless, it has been of some benefit in other cases, delaying the 
course of the disease apparently, and many of the lesions, even 
in the tumor stage, involuting. Salicin in my hands has done 
even better in producing involution of the tumors in the pre- 
ulcerative stage; and, in one case, thyroid extract had a similar 
effect. When, however, ulceration or fungation has set in, none 
of these drugs are of any use. In one case in my cognizance 
cacodylate of soda was tried, but had less good effect than in- 
jections of Fowler's solution. 

In one of my cases all the non-ulcerating tumors cleared up 
under salicin, while the ulcerating tumors proceeded unchecked 
and killed the patient by septic absorption, in spite of iodoform 
and other local antiseptics. I tried injections round the tumors, 
in one case, of both carbolic acid and perchlorid of mercury, 
and also thiosinamin; and Mannino tried resorcin injections, but 
without any success. Anything that produces a high tempera- 
ture has a good effect. Thus one of my patients was almost 
cured, and of course almost killed, by an attack of double 
pneumonia. Another improved very much during a malarial 
febrile attack, and, as before mentioned, erysipelas has quite 
cured one case, and a controllable erysipelas serum would be 
worth trying in such a desperate disease, although Besnier tried 
streptococcus serum, and Gilchrist Coley's fluid unsuccessfully, 
and I know of another unsuccessful case. 

The other case, in my own cognizance, which got well was 
due, as far as I could ascertain, to continued purgation given 
by a doctor who did not recognize the disease, but wished to 
purify the blood. These facts all point to the existence of a 
toxin as the pathogenic factor, and make one hopeful that a 
successful treatment may be discovered. 

According to Yidal and O. Simon, pyrogallic acid in the form 
of ten to twenty per cent, ointment is of service as a local ap- 
plication. Besnier recommends camphorated naphthol in the 
same way, guarding the surrounding skin, and watching the 
urine so as to stop as soon as there are signs of absorption, 
as both the drugs are dangerous to life if absorbed in large 
quantity. Besnier has also given camphorated naphthol in drop 
doses in a capsule by the mouth, and Brocq has injected it into 
the tumors with some improvement. Norman Walker relates 



YAWS. 1057 

a case of Allan Jamieson's in which local improvement ensued 
after exposure to the Rontgen rays; and Brooke has had a 
similar experience in a youth with multiple nut-sized tumors, 
but the diagnosis was not conclusive in the latter case. 



YAWS.* 

Deriv. — From Carib, ydya, the meaning of which is doubtful. 

Synonyms. — Frambesia (Fr., Framboise, a raspberry); Pian; 
Ger., Beerschwamm; Paranghi (Ceylon); Amboyna button; 
Coco (Fiji), etc. Tonga (New Caledonia). 

Definition, — An endemic specific and contagious disease, char- 
acterized by raspberry-like nodules, with or without constitu- 
tional disturbance. 

Yaws is a disease confined to tropical climates. It is found 
chiefly on the west coast of Africa for about io° each side of 
the equator; also on the east coast and in the central regions, 
rarely in the north; in Madagascar and the Mozambique ex- 
tensively; in Ceylon; in Hindustan (Pondicherry and Assam); 

* Literature. — Government Report on Yaws in West Indies, by A 
Nicholls, with, colored illustrations (Eyre and Spottiswood. 1894). In New 
Sydenham Society, vol. for 1897, of selected essays, there is an epitome of 
this Report by Wallbridge and Daniels, with critical observations; " The 
West Indian and Fijian Disease"; a translation of Charlouis's valuable 
paper of i88r. on Yaws in Java; also of Breda's paper on Boubas in 
Brazil, with a different symptomatology to the rest, as they were all cases 
of long standing. " Yaws," by J. Numa Rat, with preface by J. Hutchin- 
son (London, Waterlow, 1891), with bibliography to 1887. Gavin Milroy, 
Report on Leprosy and Yaws in the West Indies in 1873; also in Med. 
Times and Gas., November, 1876, and February, 1877; also January, 1880, 
an article by Nicholls, and, in April, 1880, an article by Bowerbank. In 
Brit. Med. Jour., vol. ii. (1881), p. 712, is a good article on Parangi, 
abstracted from Kynsey's Report to the Government of Ceylon: the 
Report itself, with an excellent series of original drawings, is in the 
library of the College of Physicians. Hirsch's " Handbook of Geographi- 
cal and Historical Pathology," Syd. Soc. ed., vol. ii. p. no, contains a 
good account of yaws and button scurvy, with bibliography. Manson's 
"Tropical Diseases," 2d ed. (1900), p 455- His description is taken 
chiefly from Nicholls', and differs in some points from the one here given. 
Jeanselme, "Pian" '(as observed in French Indo-China), (La Prat. 
Derm. s vol. iii., 1902). Also recent issue illustrated, N. Syden. Soc. Atlas, 
1902. 

67 



1058 DISEASES OF THE SKIN. 

in some of the islands of the East Indies; in the Oceania 
groups, and in the West Indies, especially Dominica and Ja- 
maica; and in tropical South America, especially Brazil, Cen- 
tral America, and Mexico. It is probable that the button scurvy 
of Ireland, now extinct, but described by various writers from 
1823 to 1857 as a contagious disease which was prevalent in 
the south and interior of the island, was closely allied to yaws,, 
if not identical with it. 

The first mention of the yaws disease is by Oviedo (1535), 
who met with it in St. Domingo; but it is to Sauvages at the 
end of the eighteenth century, and to writers of the last thirty 
years, such as Gavin Milroy, Imray, Nicholls, and Bowerbank in 
the West Indies, Kynsey of Ceylon, MacGregor of Fiji, Numa 
Rat of the Leeward Islands, Charlouis and French colonial sur- 
geons, that we owe our present knowledge of it. 

Numa Rat, from whom the following account is chiefly taken, 
as Kynsey did formerly, divides the disease into four stages — 
incubation, primary, secondary, and tertiary; now, however, 
Kynsey considers that it should be incubative, febrile, and 
eruptive, and that if there are sequelae they are accidental. 

The incubation stage is taken from the date of infection to the 
first appearance of the local lesion at the site of inoculation, and 
varies from three to ten weeks,* the former being the usual 
period. There is some dryness and branny desquamation of the 
skin, especially round the lesion, which may recur or persist into 
the later stages; beyond this there are usually only vague 
symptoms, perhaps palpitation, vertigo, and edema of the limbs 
and eyelids. The primary stage is that of the initial lesion, and 
consists of a pin's-head papule, which at the end of seven days 
has a yellow cap; in another week the fluid dries into a scab, 
beneath which is an ulcer with perpendicular edges and clean 
base. This heals in a fortnight under treatment, leaving only a 
superficial scar, or it may take two months without treatment. 
Less commoaly, the papule may slough out, leaving a clean 
ulcer the size of a florin, or it may be a non-ulcerating nodule, 
which becomes absorbed with desquamation over it, or it may 
be deep-seated, and ultimately discharge through several 
minute openings. Finally, the local lesion may be, if not missed 

* Experimental inoculation gives a shorter period, viz., twelve to 
twenty days (Paulet), fourteen (Charlouis). 



YAWS. 1059 

altogether, unobserved. The initial lesion is most frequently 
found on the lips, areola of the breast, the groin, genitals, or 
perineum, or on the feet in those who go barefooted. 

A. Powell * strenuously disputes the existence of this initial 
stage, and quotes Prout, Xicholls, Rochas, and Paulet as all 
agreeing that the initial lesion is exactly like the subsequent 
lesions, or it may be absent altogether. Some authors lay stress 
on a single yaw preceding for some time the general outbreak, 
the " mother yaw " of the natives, who think the rest spring 
from it. It is said that it often persists throughout the course 
of the disease, and may even be the last to heal. Xicholls and 
Daniels, while admitting the existence of a " mother yaw " in 
some cases, state that it is exceptional, and has no practical im- 
portance, as it is like all the rest, though some say it has an 
indurated base which the later ones have not. 

The secondary stage usually comes on about a fortnight 
after the sore has healed, i. c, about a month from the onset. 
There is intermittent fever, usually of a quotidian type, with 
headache, backache, and shooting pains in the limbs and inter- 
costal spaces like those of dengue, and with nocturnal exacerba- 
tions. The lymphatic glands generally are enlarged, those near 
the site of inoculation especially. Albuminuria, hematuria, and 
epistaxis may be present. In adults and some children the gen- 
eral symptoms may be slight. The eruption, which appears with 
the general symptoms in a typical case, consists of minute red 
spots like lichen tropicus. It appears first on the face, and 
develops from above downwards, so that the whole body is 
covered at the end of three days, but the trunk is least affected 
as a rule. Many of the spots enlarge to distinct conical papules, 
but the greater portion fade after the third day. By the sev- 
enth day the apex of the papule is of a pale yellow color, which 
Rat considers to be inspissated sebum, and a black skin has the 
appearance of being dotted over with yellow wax. The papules 
then develop into nodules of a cylindrical shape, with a dome- 
shaped thick yellow crust, f the whole, in a typical fully devel- 
oped lesion, being one-fourth inch across and one-eighth inch 
high. Underneath the crust is a mass of granulation tissue, 

*" Yaws in India," Brit. Jour. Derm., vol. viii. (1896). p. 457. 
f This yellow cap may adhere closely or be detachable from the pres- 
ence of pus beneath it (Daniels). 



1060 DISEASES OF THE SKIN. 

covered with a creamy acid secretion, and the whole looks like 
small, pieces of pickled cauliflower an inch apart, often with 
specks of red, due to dried blood from the subjacent papillae. 
It is only with the crust off that there is any resemblance to 
the raspberry, and as anemia advances the color fades to yellow, 
and even white. This full development takes about a fortnight. 
During the next four weeks, it then shrinks down until the scab 
is on the skin, but brown and dried up, soon falling off and 
leaving a pale macula, which in dark races gets darker than 
the normal, but in pale races remains paler than the natural 
skin, and in either case is scarcely ever obliterated. Intense 
itching is almost always present, and there is a sour, musty 
odor, which becomes offensive in severe cases.* More or less 
intense anemia is also a constant symptom. 

Such is the course of the disease in a healthy infant or child 
in which the disease runs an acute course, and Rat says seldom 
recurs, whereas other authors say relapses are very common; 
but in adults it has a tendency to become chronic, and produce 
the later lesions of the tertiary stage. In unhealthy subjects the 
nodules may coalesce into widespreading superficial ulcers, 
which interfere with the usual course of the disease. 

Variations. — The nodules may vary in number and size from 
a millet seed to a walnut when single, or they may coalesce 
into a large patch of granulation tissue under a single crust, 
or they may form rings round the eyes, nose, mouth, or anus, 
or inclose sound skin (ringworm yaws). In the last position 
the crusts get rubbed off, and then the lesions resemble the 
mucous patches of syphilis. In unhealthy subjects, instead of 
the nodules being .absorbed and healed in six weeks, they will 
go on for nine months or more if untreated, or they may break 
down into ulcers, which, however, readily heal under treatment. 
On the palms and soles the most frequent position in the later 
stage, the horny covering prevents the protrusion of the nodules, 
and they are then painful on pressure, c. g., in walking, hence 
the " crablike gait," and a perforating ulcer on the ball of the 
great toe may ensue. Lesions may also be produced on the 
nasal mucous membrane, mouth, or glans penis, or auditory 
meatus, and produce great pain, but as a rule the painlessness 
of yaws is a characteristic feature when fully developed, but 
* Powell {loc. cit.) says that in coolies who wash daily fetor is absent. 



YAWS. 1 06 i 

Charlouis says they are painful when they first appear, and 
that it is only the later batches which are painless. 

Sometimes the nodules abort, leaving a persistent scaliness, 
with loss of pigment, or follicular pustules may form below the 
elbow or knee, and persist after the usual nodules have gone. 
There is no alopecia or other damage to the hair, except on the 
site of the lesions, where the follicles are destroyed. Onychitis 
sometimes occurs, with shriveling and irregularity. Muscular 
contractures, probably from infiltration, and nodes may appeal 
on the cranium, clavicle, ribs, ulna, tibia, and metatarsal bones 
during the secondary period. The tertiary period occurs in 
those who have a special predisposition, constitutional debility, 
or who have bad hygienic surroundings or have had injudicious 
treatment. The lesions are no longer limited to the skin, but 
involve the deep tissues. Then the superficial ulcers get deep 
and lose their characteristic crusts, and heal with distorting 
cicatrices, the neck, front of the elbow, wrists, back of the hand, 
and instep being favorable positions for them. The duration 
of the disease averages two years, but varies between three 
months and four years. 

A serpiginous ulceration may occur several years after the 
secondary period. Successive rings of nodules, which ulcerate 
and heal, may form round the ankle and leave narrow cicatricial 
concentric rings. Granulation nodules, as in the secondary 
period, may also be formed, and nodules like syphilitic gum- 
mata often break down into ulcers, especially about the ankle 
or instep, or they may remain unchanged for months, and 
eventually be absorbed, but are prone to recur unless com- 
pletely destroyed. Other late manifestations are: Destructive 
ulceration of the nares, pharynx, and soft palate, which are 
chiefly seen at puberty after yaws in earlier life ; diffuse chronic 
periostitis, as well as the nodular form of the secondary period, 
may occur with great pain; dactylitis and arthritis may be seen; 
permanent contractures also are seen at this period; anemia 
and marked cachexia are present in severe cases, and death may 
occur from exhaustion, pyemia, septicemia, or intercurrent in- 
flammations, but it is seldom fatal if properly treated, and it is 
often remarkable that the lesions may be severe, with very little 
disturbance of the general health. 

There is still a good deal of dispute as to the tertiary lesions. 



1062 DISEASES OF THE SKIN. 

Some think they exist but are rare, many do not mention them, 
and many deny their existence as a consequence of yaws, but 
ascribe them to concurrent tertiary syphilis. Powell never saw 
them among coolies. 

Etiology. — A tropical climate is an essential factor for the 
disease, which occurs in both sexes, at any age, but is most 
common in children from two to twelve years old, while it is rare 
under twelve months. Among predisposing influences race 
comes first, negroes and East Indians being especially liable, 
but it is said that mulattoes, Creoles, and other hybrids are less 
often attacked, and it is rare in whites. Probably no race is 
exempt, but the difference in habits determines a greater or less 
frequency of exposure to inoculation. It is never congenital, 
and the modern tendency is towards disbelief in its being 
hereditary. 

It is, however, undoubtedly contagious, inoculable through an 
abrasion or sore, and even, it is said, through sound skin, flies 
being often the carriers of contagion, though some experiments 
on parangi are adverse to its being inoculable. Charlouis has 
shown that failure only occurs when the yaws lesion is in the 
declining stage. The disease is protective, as a rule, but 
Nicholls and others have met with instances of second, and even 
third attacks. Much has been attributed to the bad hygienic 
conditions in which negroes live, but these have only an 
indirect influence, aggravating the form of the disease and fa- 
cilitating its propagation, but not producing it, as it does not 
occur under the same conditions everywhere, but is strictly 
endemic. It is noteworthy that while yaws, or " coko," is com- 
mon in Fiji, syphilis is unknown among natives (Daniels); 
Koch observed the same thing in German New Guinea. 

Pathology. — It is undoubtedly due to a specific, contagious 
virus, modified by race and climate, but whether sui generis or 
that of syphilis is a moot point still, Hutchinson and some 
others holding that it is so, but most who have observed it in 
its native haunts consider it an independent disease, though it 
has many analogies to syphilis; and as I read the evidence it is 
clearly in favor of yaws being a separate disease.* Recently 

* Some powerful arguments against yaws being frambesiform syphilis 
are brought forward by A. Powell, he. ezt., and Daniels, Brit. Jour. 
Derm., vol. viii. (1896), p. 421. Beaven Rake, vol. iv. (1892), p. 376, found 



YAWS. 1063 

(1894) Nicholls and Watts claim to have found the yaws mi- 
crobe in the form of a micrococcus which invades the system 
through the lymphatics. It was always present in the granulo- 
mata and the lymphatic system, but not in the blood. The dis- 
ease has not yet been reproduced from inoculation of a cultiva- 
tion in the human subject, and animals are probably immune. 
Should these observations be confirmed and extended, the ques- 
tion will be settled. Daniels, Haffkine, and Powell have also 
found micrococci with whitish cultivation. Breda found bacilli 
in the tissue itself by soaking the section for twenty-four hours 
in alum carmine, then for half an hour in water, and then stain- 
ing by Weigert's fibrin stain; a high power is required to see 
them. 

Anatomy. — The anatomy has been investigated by Charlouis, Pont- 
oppidan,* Paulet, Ferrier, Rat, f and others. Charlouis found that the 
process was at first that of a dermatitis, confirmed to the papillary layer, 
gradually extending into the corium, and involving the appendages of 
the skin. A considerable portion of the epidermis was thrown off, the 
part of the rete still left being infiltrated with leukocytes. The exciting 
cause of the inflammation could not be discovered. Pontoppidan thought 
the process began in the rete, and found no changes deeper than the 
papillary layer. 

Unna says: The yaw is more simply constructed than a syphilid. It is 
a plasmoma of the cutis complicated with epithelial growths and hyper- 
keratosis. The strawberry appearance after removal of the crust is the 
result of the great increase of the papillary body, and its thin covering 
with the supra-papillary prickle layer. The cellular infiltration consists 
of plasma cells. Macleod's investigations agree with Jeanselme's. They 
were made on eight cases from Ceylon, and the following resume is in his 
own words. 

An examination of a large number of sections of the different lesions of 
yaws corroborated Nicholls' observation that the skin manifestations, 
namely, squames, papules, tubercles, etc., were stages in the evolution of 
a common histological process. 

A. Changes in the Corium. — (a) Vessels: dilatation and tortuosity in 
the papillary and subpapillary layers; no thickening of the vessel walls 
or endothelial proliferation; vessels persist in the granuloma, (b) Cellular 
infiltration: 1. Plasma cell infiltration at first most marked in the neigh- 
borhood of the vessels, follicles, and glands, rapidly becoming diffused ; 

none of the visceral changes of syphilis in four autopsies on yaws patients, 
but the best differentiation is Sir William Kynsey's resume, Brit. Med. 
Jour., September 21, 1901, p. 802. On the other side vide Hutchinson, 
loc. cit., New Syd. Soc. 

* Viertelj. Derm. u. Syph., vol. ix. (1882), p. 201. 

f Macleod, Brit. Med. Jour., September 21, 1901, p. 797. 



1064 DISEASES OF THE SKIN. 

no definite arrangement in rows; no large multinuclear cells (chorio- 
plaques), or true giant cells. 2. Mast cells, connective tissue cells, and 
small mononuclear cells; no tendency to organization detected. 3. 
Marked extravasation of polynuclear leukocytes, (c) Fibrous stroma: 1. 
Collagen attenuated where the granuloma is densest; no definite 
degenerative changes. 2. Elastin similarly affected, (d) Hair follicles, 
sebaceous glands, and coil glands seemed healthy. 

B. Changes in the Epidermis. — (a) Marked proliferation and down- 
growth of the interpapillary processes so great in the older lesions as to 
resemble condyloma acuminatum, (b) Basal layer uninterrupted, (c) 
Edema affecting prickle cells and interepithelial spaces, (d) Disappear- 
ance of pigment in the affected area, (e) Transitional layers imperfect. 
(/) Cornification: marked hyperkeratosis and parakeratosis with deposi- 
tion of leukocytes and debris between the horny lamellae. 

Bacteriology. — A specific microbe was not definitely detected, though 
cocci, micro-bacilli, and sarcinae were found in the horny crusts. 

Differential Histological Diagnosis. 
Yaws belongs to the group of the " Infective Granulomata." It is dis- 
tinguished from: 1. Actinomycosis and rhinoscleroma by the absence of 
their specific micro-organisms. 2. From the lepromata by the absence 
of Hansen's bacillus. 3. From mycosis fungoides by the absence of 
" fragmentation " of the infiltrating cells, and of degenerative changes 
with the formation of products of degeneration in the collagen and elastin; 
by the presence of the peculiar epidermal changes of yaws. 4. From 
tuberculosis, apart from the tubercle bacillus, by the absence of the 
characteristic architecture with its giant cells, daughter plasma cells, 
more marked disintegration of the fibrous stroma, and complete dis- 
appearance of the blood-vessels. 5. From syphilis, by the following 
details which, considered collectively, strongly suggest that yaws and 
syphilis are different histological entities, (a) Cellular infiltration: 
plasma cells not so definitely arranged in rows or clustered round the 
blood-vessels as in syphilis; no large multinuclear cells (chorio-plaques), 
or true giant cells, or intracellular hyalin degeneration noted in yaws. 
(b) Fibrous stroma: rarefaction of the collagen more marked than in 
syphilis, but no organization or colloidal degeneration (such as occurs in 
syphilitic gummata) found, (c) Blood-vessels: no distinct proliferative 
changes in the vessel walls or endothelium, as frequently occurs in syphilis. 
(d) Epidermis: marked proliferation and downgrowth of the epithelium, 
with a great thickening of the horny layer (due to hyperkeratosis or para- 
keratosis) are characteristic features of yaws, while they are unusual in 
syphilis. 

Diagnosis. — The most characteristic features are the initial 
papule, which enlarges to fungating nodules with an acid secre- 
tion, and covered by a yellow crust. When this is removed it 
leaves bare the raspberry-like tumor, which remains stationary 
for weeks or months with yellowish discharge, not painful on 



YAWS. 1065 

pressure, and tending to heal spontaneously without scarring, 
unless irritated into ulceration, or in cachectic conditions; the 
disease, as a whole, tending to spontaneous recovery, except in 
bad hygienic conditions. Loos and others have endeavored to 
separate the parangi of Ceylon from West Indian yaws, but the 
supposed distinctions break down on close examination, and 
Sir William Kynsey has no doubt of their identity. The button 
scurvy of Ireland is also admitted to be a form of yaws. The 
differences from syphilis, according to Numa Rat, are princi- 
pally the fungous eruption with acid secretion and the absence 
of enlarged glands (these, however, are mentioned by some 
authors). Other differences are, no induration of the initial 
lesion, which is never phagedenic, and usually extra-genital. 
The characteristic eruption is not symmetrical or polymorphous, 
but has constant characters unmodified by age, sex, or race; 
it is rarely pustular, and does not leave scars unless irritated or 
injured. The lesions of the mucous membranes are never pres- 
ent until after the secondary stage, generally years after. No 
alopecia or other hair change, no eye changes such as iritis, 
no ulcers of tongue, anus, or rectum. Mercury is injurious in 
the primary and early part of the secondary stage, and iodids 
are much less efficacious than in syphilis in the tertiary stage. 
In yaws the following characteristic symptoms of hereditary 
syphilis are absent: Notched teeth, rhagades round the mouth, 
mucous patches, enlarged spleen, bullous syphilids of palms and 
soles, osteophytes and epiphyseal enlargements, eye and ear 
lesions. Even these are not the only differences; one very nota- 
ble feature being that, when yaws is not injudiciously treated 
the lesions are limited to the skin, and less frequently to the 
mucous membranes. 

Two cases have been observed by Powell and two by Char- 
louis, in which persons with yaws have contracted syphilis, with 
the usual symptoms co-existing with the yaws lesions, which 
disproves Daniels' statement that co-existent syphilis always 
precedes yaws. Yaws when inoculated always breeds true. It 
is probable that in their descriptions some authors have mixed 
the symptoms of syphilis and yaws. 

Treatment. — Improved hygenic conditions are always most 
important. The most careful cleanliness and nutritious but un- 
stimulating diet, tonics, diaphoretics, and, locally, disinfectant 



io66 DISEASES OF THE SKIN. 

applications, carbolic or boric acid lotions, and diluted nitrate 
of mercury ointment, are recommended by Imray, who also sug- 
gests that at first, sulphur and acid tartrate of potash should be 
given for a week to bring the eruption out thoroughly, as when 
it fails to develop well in the early stage the patient becomes 
cachectic, and septic symptoms may ensue. 

Powell has observed that an attack of malaria or other disease 
attended with fever has very often a curative effect on the fully 
developed lesions, but stimulates those in the papular stage, and 
in 1784 Naubhard noted that smallpox cured yaws. 

Rat lays great stress upon healing a previously existing sore, 
if it is the site of inoculation, as it prevents the development 
of the eruption. He also recommends iron, preferably the tar- 
trate, and cod-liver oil, and for the febrile condition, quinine or 
salicylate of soda. He is a strong advocate for diaphoretic 
measures after the febrile symptoms have subsided, ammonium 
carbonate being preferred on account of its being alkaline as 
well as stimulant and diaphoretic; and he lays great stress on 
promoting alkalinity of the secretions. For the characteristic 
nodules he recommends sulphur baths, natural or artificial, and 
calomel fumigations. After the nodules have dried up iodid of 
potassium and tonics should be given for another six weeks. 
If the lesions are obstinate, Donovan's solution in doses of TTtv 
to TTLx is recommended. In the tertiary stage Rat still gives 
mercury and iodid of potassium combined, or the calomel 
fumigations and full doses (gr. 15) of iodid. He believes that, 
as in syphilis, mercury alone cures, iodids only alleviate. All 
are, however, agreed that it should not be given in the early 
stage, and that its administration requires care and watchful- 
ness, or it will do more harm than good. 

Charlouis obtained the best results by applying ung. hydrarg. 
to the nodules, and giving iodid internally, but iodid alone only 
relieved the bone pains, but for these iodoform pills five grains 
three times a day gave immediate relief. 

The various sores are best treated by washing with weak 
perchlorid of mercury lotion, and the application of iodoform, 
either dry or as an ointment. Black wash is also often useful. 
In Breda's Brazilian cases of long standing, nothing except 
erasion had any effect. 



VERRUGA PERUANA. 1067 

VERRUGA PERUANA.* 

Deriv. — Verruga, Spanish for a wart. 
Synonyms. — Peruvian wart; Carrion's disease; f Oroya fever. 

This disease is mentioned as early as 1543 by Zarate, in his 
" History of Peru," but Tshudi in 1845 gave the first good medi- 
cal account of it. It is a narrowly endemic disease, with occa- 
sional epidemic outbreaks, being confined to the narrow gorges 
of the Western Andes in Peru; J and it is not in any way con- 
nected with yaws, with which it is usually confounded, the single 
fact that whites suffer more frequently and severely than negroes 
or Indians being an important distinction, enough to separate the 
two diseases. Verruga is certainly inoculable,§ and it is highly 
dangerous to stay in the diseased centers even for a short time, 
but this is possibly analogous to the effect of the malarious 
parasite. It appears to be an acute specific affection, which 
affects animals — the horse, ass, mule, and dog — as well as man. 

Symptoms. — The outbreak of the eruption is preceded for 
some weeks or even months by severe febrile symptoms, of 
which a cramplike contraction of the gullet was said by Dounon 
to be the most characteristic, but Castillo and others say that 
it only occurs when there are pharyngeal verrugas. 

There are also cramps in other muscles and severe pains with 
great prostration, and sometimes death before the eruption has 
time to develop, constituting Oroya fever. || 

* Literature. — Hirsch, loc. cit., vol. ii. p. 11 j. Plate XLI., Frambesia, 
Sydenham Society's Atlas, represents this disease— an account of the case 
is given p. 145 of the catalogue. Beaumanoir, " De la verruga," Archives 
de Med. Navale Colotiiale, January, 1S91, p. 1. A good abstract in Ann. 
de Derm, et de Syph., vol. ii. (1891), p. 818, also vol. x. (1898). p. 59. Abs. 
of Chastang's Memoir, loc. cit., 1897, p. 417, Brit. Jour. Derm., vol. x. 
(1899), p. 59. 

f " Odriozola " ; monograph with plates, published in Paris, 1898. Mor- 
row's System, Gen.-Ur. Dis., Derm, and Syfi/i., vol. iii. part ii. p. 707, 
gives a very extensive bibliography to 1891. 

Jin Lancet, November 10, 1883, Dr. de Haviland Hall describes a 
peculiar disease met with at Zaruma in Ecuador by Mr. Aldridge, which 
corresponds in many respects with verruga. 

§ In the Lancet, 1886, is the case of Carrion, a Peruvian medical student 
who experimentally inoculated himself from a verruga lesion, was taken 
ill on the twenty-second day, and died on the thirty-eighth, before any 
eruption appeared, with the symptoms of " Oroya fever." 

I The name arose from the terrible mortality which was produced in 



1068 DISEASES OF THE SKIN. 

There is great destruction of red corpuscles, from half to 
one-third or even less. 

Ordinarily these symptoms remit or vanish with the appear- 
ance of the eruption, which begins on the face and limbs and 
spreads over the rest of the body; or the eruption may be de- 
layed until after the spontaneous subsidence of the general 
symptoms; or again the latter may be reproduced after the 
eruption is out. The lesions are lentil- to pea-sized, raised pink 
spots, which develop into cylindrical, conical, or hemispherical 
tumors, from a raspberry to a pigeon's egg, or even an orange 
in size and in shape, cylindrical, conical, hemispherical, or 
fungiform. The consistence is soft or elastic, according to the 
rate of development, and the surface is tender, thus contrasting 
with the painless lesions of yaws. They are highly vascular 
and their surface is smooth and shining. Sometimes they de- 
velop from vesicles of various size, or from pustules instead of 
from pink spots. When the tumor is fully formed the epi- 
dermis thins over it, cracks, and bleeding is easily induced, very 
copious, difficult to control, and producing profound anemia. 
The tumors may either dry and shrivel up and peel off, or dis- 
integrate into ulcers. The number of the excrescences ranges 
from one to several hundreds, of all sizes, most abundant on 
the extremities, face, scalp, and neck, sometimes on the palms, 
and soles, but rarely on the trunk. They may be subcutaneous, 
choosing then the elbows and knees, or the legs and ankles. 
They may be absorbed or break down into ulcers, which fun- 
gate and have an offensive discharge. Any or all of the mucous 
membranes may also be involved, and hemorrhages may occur 
both from the mouth and anus. The liver, spleen, kidneys, or 
brain may be involved also. The disease generally lasts two or 
three months, sometimes more,* but it may be fatal earlier from 
hemorrhage, or when death occurs before the eruption appears. 
The duration may be only a few days or weeks. 

In cases which survive there may be left profound anemia, 

the laborers constructing the Callao to Oroya railway, 1870-74. Oroya 
itself is not a place where the disease is endemic. The symptoms were 
those of malignant malaria with a mortality of seventy per cent. , and there 
was no eruption, except in some of the milder cases which survived. 

* There have been rare instances of a very mild outbreak of a few 
lesions long after the patient has left the district. In one case two 
lesions appeared two years after. 



FURUNCULUS ORIENTALIS. 1069 

dropsy, or nervous complications. The mortality is from 6 to 
10 per cent, in the natives, 12 to 16 among whites, or in epi- 
demics 40 per cent., while in Oroya fever it may reach 90 per 
cent. The lesions consist of highly vascular granulation tissue, 
cavernous tumors, which take their origin from the superficial 
or deeper layers of the corium, and if they disappear, do so by 
absorption, ulceration, crusting, or suppuration; the last is rare. 
Yzquierdo has found a bacillus or streptococcus larger than 
that of tubercle in the tissue interstices, as well as in the vessels 
which may be occluded by them; whether it is really the materies 
morbi remains to be proved. 

The most important point of the treatment is the immediate 
removal of the patient from the endemic area; large doses of 
quinine have not been of much service, but large doses of 
perchlorid of iron were successful in the treatment of the 
analogous cases of Mr. Aldridge of Zaruma. As in yaws, it 
is considered advisable to encourage the development of the 
eruption. 

It is significant that the worst forms have occurred where 
large masses of earth have been disturbed; that it has disap- 
peared where the soil has been drained; and that it has occurred 
chiefly among those who have bathed in or drank of the waters 
of the district. It would be interesting to investigate whether 
mosquitoes play a part in its propagation. 

FURUNCULUS ORIENTALIS.* 

Synonyms. — Oriental boil; Aleppo boil; Delhi boil; Biskra or 
Biscara button; Gafsa button; Kandahar sore; Pendjeh 
sore; Annamite ulcer; Gaboon ulcer, etc.; Fr., Clou de 
Biskra; Ger., Orientbeule. 

Definition. — A local disease, occurring chiefly on the face and 
other uncovered parts, endemic in limited districts in hot cli- 
mates, characterized by the formation of a papule, a nodule, a 
scab, and under the last, a sharply-punched-out ulcer. 

This disease is common in certain districts of tropical and 
subtropical climates from 23 to 45 N., and from 2° W. to 

* Literature.— -St. Louis Atlas, Plate XXXII., Model in Coll. Surg. 
Museum, No. 317, Dermatological Series. " Delhi and Oriental Sore," 
by Dr. J. Murray, Trans. Epidem. Soc, vol. ii. (1883), p. 90 — a good 



1070 DISEASES OF THE SKIN. 

8o° E. The local names indicate most of the localities, to which 
must be added the southern and eastern littoral of the Mediter- 
ranean, Crete, Cyprus, the Crimea, and Persia, where it is very 
prevalent. 

The Puru * of the Malay peninsula is the same disease, and 
it is endemic in Bahia. f Peacocke in 1845 an d Russell in 1756 
first described the disease as they saw it in Aleppo. Natal sore 
is probably " the Veld sore." 

Symptoms. — It is an entirely local disease, unattended by con- 
stitutional disturbance, but it has a period of quiescence after 
inoculation of from three days to several months. It occurs 
chiefly in uncovered parts, especially the face, any part of which 
may be attacked, but the cheeks, angles of the mouth, alse nasi, 
the ears, and the orbits are the favorite seats. The scalp is 
never attacked; it may occasionally be seen on the extremities, 
especially the back of the hand or foot, but is quite exceptional 
on the trunk or pubes. Commonly, there is one so-called boil, 
but there may be several, and as many as ninety have been 
counted scattered over the face and body. It begins as a red 
papule, like an irritated mosquito-bite, gradually enlarges to the 
size of a pea or bean, of a dull red color, and the surface is 
undisturbed, smooth, and shining for weeks or months, but with 
a lens the red surface can be seen to be studded with deep- 
seated, yellowish-white points like milium. 

Then, from a small central aperture, thin, clear serum begins 
to ooze, and dries into a closely adherent brown crust, which 
gradually enlarges in thickness and area. Beneath this scab the 
nodule gradually disintegrates, until a round ulcer from three- 
quarters to two inches in diameter is formed, with a red areola 
beyond. The edges are sharp and irregular, the ulceration may 
penetrate into the subcutaneous tissues, the floor is uneven, 

account, with photographs. Hirsch, he. eit., vol. iii. p. 668, with bibli- 
ography. Woolbert of Meshed sent me an interesting series of drawings 
made on the spot, together many clinical observations which I have in- 
corporated in the text. 

* " Puru, a contagious form of Lupus occurring in Malay," by W. C. 
Brown, Penang, Brit. Jour. Derm., vol. v. (June, 1893), p. 161, with 
photograph. 

f De Souza of Bahia, Portuguese Thesis, 1895; abs. Brit. Jour. Derm., 
vol ix. (1897), p. 129. Tuliano in 1890 also described it as a disease of 
Bahia. 



FURUNCULUS ORIENT 'ALIS. 107 1 

fungating in one part and disintegrating in another, secreting 
a thin, offensive pus, which, if allowed to dry, forms thick, ad- 
herent crusts. The primary ulcer is small, and may remain so, 
but ulcers several square inches in area may be formed by the 
coalescence of secondary ulcers round it. After some weeks or 
months the fungoid granulations give place to more healthy 
ones, which gradually fill up the excavation more or less com- 
pletely, and the sore ultimately cicatrizes, the scar being more 
or less puckered towards the center, and pigmented of a uniform 
brown color; the whole process lasting three to twelve months, 
or even two years. Some cases last much longer than this, by 
the sore breaking down repeatedly after cicatrization, healing in 
winter and ulcerating in the summer. From reinfection fresh 
regions of the body may be invaded several years after the 
original sore has healed. Uncomplicated cases heal and leave 
only scars, which may disfigure the face and cripple the limbs 
by their contraction. If secondary complications occur, such 
as lymphangitis, erysipelas, or glandular enlargements, or the 
ulceration is very extensive with cachexia, from leprosy or 
other cause, there may then be danger to life. Small nodules 
beyond the ulcer sometimes form along the course of the lym- 
phatic vessels, but the glands as a rule are not then enlarged. 
Etiology. — No sex, race, age, or nationality gives exemption 
when brought within its influence. At the same time it is most 
common in children after the second year, rarely appearing be- 
fore that, and in Aleppo few native children reach the age of 
seven without having had it; it may, on the other hand, affect 
people of forty or fifty, or even older. As a rule, strangers do 
not get it until they have been some time in the district, but 
occasionally only a few days' sojourn is sufficient, and in some 
people, like leprosy, it only appears after they have left the dis- 
trict. Its strict limitation indicates that climate has some influ- 
ence, but it is usually considered to be independent of the nature 
of the soil. Besnier, however, disputes this, and Tilbury Fox 
considered that it was of malarious origin. It is seen chiefly in 
the latter part of the summer and in autumn, e. g., in September, 
October, and November in subtropical climates, and in the first 
part of the cold season in the tropics. Numerous theories have 
been put forward to explain how it is excited, and a considerable 
body of evidence favors the idea that it is the water of the dis- 



1 072 DISEASES OF THE SKIN. 

trict which contains the infecting parasite; and the members of 
the Government Commission to investigate the Delhi sore were 
of the opinion that it gained access to the body, not by drink- 
ing the infected water, but through some abrasion or scratch 
while washing or bathing in it. This Commission, of which Dr. 
J. Murray was president, and since that Deperet and Boinet also, 
have definitely proved that it is inoculable both in men and 
animals, and flies and other winged insects are plausibly con- 
sidered by Laveran to be frequent carriers of the infection. 
There is no reason to believe it to be hereditary. 

Pathology. — The balance of evidence is in favor of its being 
an infective and destructive inflammation, set up by a vegetable 
organism, but, in spite of numerous investigations, the exact 
organism has not yet been demonstrated. Smith's, Fleming's, 
and Carter's observations were clearly erroneous. Cunning- 
ham's monadines (refractile bodies larger than lymph corpus- 
cles), according to the more recent investigators,* Riehl and 
Paltauf, are the same as the hyaline globules which they have 
described, and not, therefore, parasites at all. 

Deperet, Boinet, Duclaux, Chantemesse, and Poncet de 
•Cluny, however, have found diplococci, but not the same, both 
from the boil itself, and from blood near it, and inoculation with 
culture fluid failed to produce the disease; for though suppura- 
tion and even death in animals was produced, the symptoms 
were very different from Oriental boil. Paltauf's inoculation 
experiments were also negative. Leloir f obtained an organism 
similar to those of Duclaux and Heydenreich, and considers it 
in all probability the pathogenic agent; it consists of cocci in 
twos or conglomerations. Auche and Le Dantec J found 
streptococci which produced on the rabbit something like the 
original sore. De Souza's observations support those of 
Duclaux. On the other hand, Geber,§ who investigated the 

*" Zur Anatomie und ^Etiologie der Orientbeule," Viertelj.f. Der7n. 
u. Syph., vol. xiii. (1886), p. 805, gives a good summary of previous in- 
vestigation on these points. 

f Leloir et Vidal. i re livraison, Plate VI., 2 me liv., p. 87; also Loustalot 
" Le bouton de Biskra," "These de Lille," 1888, contains Leloir's obser- 
vations. 

% Auche and Le Dantec, Note on "Biskra Button," A rchives Clin, de 
Bordeaux, October, 1894, Abs. Brit. Jour. Derm., vol. vii. (1895), p. 98. 

%Archivf. Derm. u. Syph., 1874, Heft iv. 



FURUNCULUS ORIENT ALIS. 1073 

matter at Aleppo, believes that there is no specific disease at all, 
but that it is a medley of syphilitic, lupus, strumous, and other 
ulcers, all classed as the one disease. Although, doubtless, such 
errors are often made, there is no doubt that there is an endemic 
ulcer sui generis. 

Anatomy. — Unna* gives a summary of the anatomical investigations, 
and concludes that the process is a chronic sero-fibrinous inflammation 
of the whole cutis, which leads in the center to necrosis, softening, and 
consequent ulceration, comparable to tertiary syphilitic ulceration, and 
considers that the lesion stands midway between an ulcer and a new 
growth. In De Souza's thesis observations there was hypertrophy of all 
the layers of the epidermis, but chiefly of the rete, with downgrowths 
and epithelial nests like those of epithelioma. There was cell infiltration, 
either as single or grouped islets or diffusely infiltrating the corium or 
even below, and it was in these infiltrations that the epithelial nests were 
found. 

Diagnosis. — In the district where it is known to be endemic 
there would be no difficulty. The isolated papule developing 
into a nodule, and this exuding, crusting, and then disintegrat- 
ing into an ulcer under the crust, and its situation on the face 
or other exposed part, constitute a distinctive set of symptoms; 
but as so experienced an observer as Murray considers this 
affection identical with yaws, it may be as well to compare the 
two affections, which doubtless have some points in common, 
but have many important differences. 

Yazvs is preceded by febrile symptoms ; Oriental boil by none. 
In yaws the lesions are always multiple and often in crops; the 
boil is single, as a rule, and if more than one, they are rarely 
numerous; while both attack the face, yaws prefers the palms 
and soles; the boil, the back of the hands and feet. The lesions 
of both are papules succeeded by nodules, but in yaws the 
epidermis splits off in a few days, and the whole eruption is 
developed in from two to four weeks, but the nodules of the boil 
remain unchanged for weeks or months. When the crust of the 
boil is removed an ulcer is exposed; when that of yaws is re- 
moved a moist tumor is brought into view, and yaws never 
ulcerates, except when irritated, and in cachectic subjects. The 
yaws tumors dry up and fall off, leaving no scar; the boil neces- 

* Unna's Histopathology, p. 476, with pathological references. 
68 



1074 DISEASES OF THE SKIN. 

sarily leaves a deep scar. Finally, yaws, while very prevalent 
among the colored races, seldom attacks Europeans, while the 
boil impartially attacks all within its sphere of influence. 

Prognosis. — This is decidedly good for recovery, a fatal issue 
being rare, and only in very cachectic individuals; but disfiguring 
and disabling cicatrices may be left, unless the case comes early 
under treatment. The patient is not, however, protected either 
from recurrences or fresh inoculation. 

Treatment. — In the early or " mosquito-bite stage," Murray 
recommends the actual cautery to completely destroy it; when 
available, Paquelin's or the galvanic cautery would be the .most 
convenient means for the purpose, but it is seldom seen in this 
stage. I should be inclined to try three per cent, carbolic acid in- 
jections in the same way as for carbuncle, round the boil area 
before it has broken down. Woolbert, practicing in Meshed, 
Persia, where the disease is very common, finds that, when the 
whole boil area has ulcerated, scraping away the granulations 
and applying nitric acid produces rapid healing. Other caustics, 
such as caustic potash, or the fuming acid nitrate of mercury, 
solid nitrate of silver, or pure carbolic acid, are also useful. 
After destruction of the diseased tissue the ordinary treatment 
for simple ulcer is sufficient, c. g., carbolized or boric lint, or 
corrosive sublimate lotion, under oiled silk, or iodoform dress- 
ings may be applied. The prophylactic treatment is to avoid the 
infected water, both for washing and drinking, unless it has been 
boiled. Dr. G. Ranking,* like Fox and Besnier, regards the 
ulcer as of malarial origin, and says that if large doses of arsenic 
or quinine are given, the ulcer heals readily with the simplest 
local treatment. Frog-skin grafts greatly expedited cicatriza- 
tion in large ulcers. Gaucher and Bernard found that in " Anna- 
mite ulcers " they healed readily in a month with simply ten 
minutes' spraying every day with boiled water and compresses of 
the same constantly applied. No internal medication was em- 
ployed, and they regard antiseptics as positively injurious. 
Petersen was successful in healing an " Aleppo sore " with the 
Finsen light with the minimum of scar, but it required numerous 
exposures; probably the Rontgen rays would act more quickly 
and equally efficaciously, and at all events would be more easily 1 
applied. 

* Lancet, August 27, 1887, p. 413. 






FURUNCULUS 0R1ENTALIS. 1075 

The Madagascar ulcer,* according to Fradel and Legrain, is 
a special disease, attacking the extremities with a long duration, 
leaying hard white parchment cicatrix, with a tendency to recur, 
and it may implicate the deeper tissues, including the bones. It 
is thus differentiated from Biskra button, and appears to belong 
to phagedena tropica. 

Veld Sore. {Synonym. — Natal Sore?) The South African 
war has made this sore only too familiar to our soldiers and 
surgeons, and Ogston, Harland, Harman, and others have 
written upon it. It attacked the cavalry twice as often as the 
infantry. The sores were usually multiple, occurred mostly on 
the hands and forearms, chiefly on the backs, and also on the 
feet and legs, but they were infrequent on the face, and on the 
less exposed parts of the body. A breach of surface was nearly 
always the point of entry, and Harland suggests that it is con- 
veyed by the large brown horseflies, which were very abundant. 
It begins as an itching pin's-head papule, vesicle, or pustule, 
which rapidly increases in size, with at first clear yellow serous 
fluid, which is soon turbid, easily ruptures, and becomes a pain- 
ful dirty-looking sore, usually not larger than a shilling, but 
varying from a threepenny-piece to a crown, and covered with 
a dirty scab exuding pus and serum; some inflammation of the 
lymphatics and glands are often present. Harland says that 
sometimes there may be a huge flat pustule covering the whole 
of the back of the hand and up to the forearm. Ogston says 
that suppuration is not a characteristic feature, the border being 
vesicular with a red areola, which on the arms and legs look 
like " lazy blisters," which slowly spread but will not heal, and 
it is essentially epidermic; and Harman describes it as a vesicle 
or blister in the stratum lucidum. Cultures yielded a diplo- 
coccus growing freely in ordinary media, and in some respects 
resembling staphylococcus aureus. In aerobic cultures it grew 
as a diplococcus. There seems strong reason for believing that 
it is a semi-tropical variant of impetigo contagiosa, or its 
crusted form " ecthyma." 

The cure is easily effected, Harland says, by the application 
of boric or carbolic acid fomentations, and subsequent dress- 

* Annates de Derm., vol. vii. (1896), p. 1088, and (1897), p. 781. 



1076 DISEASES OF THE SKIN. 

ing with boric ointment. No doubt the usual treatment for the 
destruction of pus cocci would be effectual. 

Harman says that the veld sore was found in the high barren 
tableland, while the Natal sore was found in the lower parts of 
Natal, where vegetable and animal life were abundant, so per- 
haps they are different affections. The veld sore yielded 
staphylococcus pyogenes aureus both to film and culture prepa- 
rations. 

The Barkoo, or Barcoo Rot, of Queensland appears to be a 
similar affection to the " veld sore." 

GRANULOMA INGUINALE TROPICUM.* 

Synonyms. — Groin ulceration; Ulcerating granuloma of the 
pudenda (Galloway). 

Definition. — A tropical disease characterized by chronic ulcera- 
tion of the groin and neighborhood, with papillary overgrowth. 

We owe the first clear account of this affection to Conyers 
and Daniels of British Guiana in 1896. It appears to be fairly 
common in British Guiana and the West Indies, but it has also 
been observed in India by J. Maitland and in Fiji by Daniels; 
probably it occurs in most tropical climates, but is confused with 
syphilis and yaws. 

A case in a negro came under my care in 1888, and subse- 
quently under that of Pringle; but while we recognized that it 
was a special form of disease, there was no published account 
to show that it was well known in the tropics. He had left the 
West Indies five years when the disease began, six months 
before I saw him, as a flat sore on the top of the penis, behind 
the corona, attributed to impure intercourse nine days previ- 
ously. He told Pringle that it began as a pea-sized boil in the 
right groin, which was scratched into a sore, and spread down 
the side of the scrotum and up along the groin. Probably that 

* Literature. — Conyers and Daniels, " The Lupoid form of the so-called 
' Groin ulceration ' of British Guiana," British Guiana Medical Annual ', 
1896. (Georgetown, Demarara: Baldwin & Co.) " Ulcerating Granu- 
loma of the Pudenda," James Galloway, Brit. Jour. Derm., vol. ix. (1897), 
p. 133; a good abstract of the above paper and original observations on 
histology, illustrated. Also the clinical history of the case which came 
first under me and then under Pringle, in 1888 and 1889. 



GRANULOMA INGUINALE TROPICUM. 1077 

was true for the groin lesion, but the penis was the primary 
point of infection. Conyers and Daniels say that papules are 
the first lesion, and that pink, smooth, shining nodules develop 
from them half an inch or more in diameter. These break down 
spontaneously, or from abrasion, and superficial, spreading 
ulceration is produced. At first smooth, it soon develops an 
easily bleeding papillary overgrowth, often with copious serous 
discharge, very offensive and sui generis. The nodule may heal 
with the formation of a good deal of firm fibrous tissue, but it 
often breaks down again, and the disease extends by the aggre- 
gation of fresh nodules which form at the margin, and are espe- 
cially large when seated at the hair or sebaceous follicles. The 
heat and moisture of the folds favor extension, and the dis- 
charges of the sores may inoculate the skin traversed by them. 

In males the disease usually starts in the groin or pubes, and 
extends in a line about half to three-quarters of an inch wide, 
the whole length of the groin, and sometimes on the perineum, 
and as far as, and even round, the anus; it may also extend 
over the pubes, where it is often very extensive, and join the 
lesion of the opposite groin. The penis may also be primarily 
or secondarily involved, and in my case there was a collar of 
ulceration at the neck of the glans. 

In females the labia or vagina are the usual starting-point, 
and in them extension along the perineum to the anus is espe- 
cially likely to occur, involving the mucous membranes some- 
times to a considerable extent. 

The aspect of a fully-developed linear lesion is that of super- 
ficial ulceration within a sulcus with a papillary, more or less 
crusted growth on each border, the whole situated on a raised 
indurated ridge. Where adjacent hot moist surfaces are in 
juxtaposition, the disease may be in plaques instead of ridges. 
Detached lesions also exist, and there may be cicatrization at 
some points, the scar being dense and irregularly pigmented, 
and if it is extensive, the blocking of the lymphatics may give 
rise to more or less elephantiasis. While, however, it is cicatriz- 
ing at one point it may be breaking down at another, and so 
all stages may sometimes be seen together. In this way the 
course is very variable, and the duration is from a few months 
to several years. 

Etiology. — The disease attacks both sexes, but is more fre- 



1078 



DISEASES OF THE SKIN. 



quent among females, at any time after puberty, and generally 
young adults, twenty-seven years being the average of Conyers 
and Daniels' cases. Negroes are said to be especially liable to it, 
but, as already said, Maitland has met with it in East Indians, 
and he is strongly of opinion that it is of venereal origin, but 
not syphilitic. Daniels has also observed it in Fiji among 
imported Melanesians, who, like negroes, are particularly liable 
to tuberculosis and keloid. The influence of race is borne out 
in the case of my negro patient, who contracted it in Paris so 
many years after he had left the West Indies. Nevertheless 
a closely analogous condition may occur even in England. A 




Fig. 62.— Papillary growth in the groin identical with granuloma inguinale 

tropicum. 

youth of eighteen came to University College Hospital on 
May 4, 1897, with a linear lesion in the groin five and a quarter 
inches long, and in width averaging three-quarters of an inch, 
but tapering to one-third of an inch at the upper end. Portions 
of the lesions were healed and of a purplish-red color, but the 
greater part was ulcerating with papillomatous surface. He 
stated that it began as a small pustule nine years previously, 
which broke down into an ulcer, and had gradually spread into 
its present condition, but it had altered very little for the last 
four years. There was no evidence of phthisis in himself or 
family, and he lived in the country under healthy conditions. 



PAPILLOMA OF THE SKIX. 



1079 



Histologically, Galloway confirmed its similarity to the tropical 
form of the disease, but the latter is contagious. 

Pathology. — Galloway,* who examined some of Daniels' ma- 
terial, pronounces it to be structurally a granuloma, with much 
elongation of the papillae and rete proliferation over them. Xo 
organism has been isolated, but to my mind it is strongly sug- 
gestive of pus cocci infection. 

Treatment. — Erasion and subsequent swabbing with carbolic 
acid appears to be the quickest and most satisfactory method 
of treatment, and if thoroughly done there will be no recurrence. 

PAPILLOMA OF THE SKIN.f 

Synonym. — xAxanthoma. 

Corns, warts, horns, and some nevi, were all formerly con- 
sidered by general pathologists as examples of " papilloma of 
the skin "; and various kinds of tumors, such as sarcoma, car- 
cinoma, epithelioma, and fibroma, as well as morbid processes 
like syphilis, lupus, eczema, and sycosis, are liable to develop 
papillary growths. 

Virchow, Auspitz, Unna, and others have pointed out that 
all the growth is really epithelial, and that there is only an 
appearance of growth of the papillae; Auspitz and Unna, 
therefore, advocate the substitution of the term acanthoma t 
(growth of the prickle cell layer). It is probable, however, that 
the old term will be retained for a long while, but it must be 
understood that it is here used as a clinical term for various 
papillary growths. While all acanthomata are not papillary, 
e. g., molluscum contagiosum, they are probably all of microbic 

* Loc. c/t., with plates. 

\ Literature. — Author's Atlas, Plate LXXV., shows a papillary epithelial 
growth on the face of a case of xerodermia pigmentosa. The epithelial 
structure of this growth is shown in Fig. 33. Hardaway, " Clinical Study 
of Papilloma Cutis," Amer. Arch, of Derm., vol. vi. (18S0), p. 387 — a good 
general review of the whole subject. Morrow, " Tuberculosis Papilloma- 
tosa Cutis," Amer. Jour. Cut. and Gen.-Ur. D/s., vol. vi. (1S88), pp. 361 
and 401, well illustrated, gives an account of very extensive primary 
growth, and discusses the question of papilloma. " Das entziindliche 
Haut-Papillom," Roser, Arch, der Heilkunde, 1866. Weil in Viertelj. 
Derm. u. Syfth.,/. 1874, p. 37, with colored plate. 

X Unna's " Histopathology," p. 784. 



1080 DISEASES OF THE SKIN. 

origin, and most, if not all, of the secondary growths are due 
to pus cocci. 

An attempt has, however, been made by Neumann, Duhring, 
and some other dermatologists to give the term papilloma a 
special meaning, on the strength of certain cases which have 
been reported as inflammatory skin papilloma by Weil and 
Roser, and under other names by various writers. It consists 
of a raised cauliflower excrescence, very like verruca acumina, 
already described, varying in size, with fissures and sinuses, 
which secrete a yellowish puriform and sometimes offensive 
fluid, occurring at any part of the body and at any time of life. 
I once saw a patch of this kind on the hip of a tubercular man 
of twenty-five, about one inch in diameter, projecting about 
one-fourth of an inch, with a scabbed covering, and hyper- 
trophied, readily bleeding papillae. There was no history of 
previous lesions, but Hardaway thinks such growths are always 
secondary to ulcers or other lesions, and calls them all symp- 
tomatic papillomata. Beigel's oft-quoted case of papilloma 
area elevatum in a child, set. twelve months, suffering from con- 
vulsions,* was evidently a case of bromid rash, in which the 
appearance of the papilloma is not infrequently produced when 
the scab is removed from the larger lesions, and they are also 
sometimes followed by papillary hypertrophy. The term " neu- 
ropathic papilloma " is often applied to the band form of warty 
growths, which really belong to the same category as ichthyosis 
hystrix. 

Instead of being in a single tumor there may be a patch of 
papillary growth. An old lady received a blow on a patch of 
eczema on the thumb; four months later there was a growth one 
and three-eighths by one inch in area, raised up a quarter of an 
inch, papillomatous in the center, with soft granulation tissue 
at the border, with the skin over it sound, but livid red, and 
looking like a lupus papillomatosus; it was gradually spreading. 
Loretin was first applied, and then salicylic acid gr. xv., un- 
guentum zinci oleatis ^j, under which it got quite well. The 
fungations which develop in the axillae and groins in pemphigus 
vegetans are probably of the same nature, and can be removed 
by iodoform and similar applications. 

* Path. Trans., vol. xx. p. 414. 



GRANULOMA PYOGENICUM. 1081 

GRANULOMA PYOGENICUM.* 

Synonym. — Botryomycosis hominis. 

'Definition. — A fungating tumor produced by pus cocci. 

Veterinary surgeons first used the term botryomycosis for an 
affection which is met with in bovines, the pig, and dog as a 
fungating granuloma which occurs most commonly in the testic- 
ular cord of the horse after castration, and may be either in or 
outside of the scrotum, inguinal canal, or abdomen. Also as 
fibrous tegumentary tumors, in the lung, maxillary, and pental 
sinus, which may be generalized. Poncet and Dor have now 
identified a similar condition in the human subject in the form 
of neoplastic fungating ulcerative granulomata, from a pea to 
a nut, developing by means of a pedicle from the derma. They 
met with it in the fingers, thenar eminence, and shoulder. His- 
tologically the growth was a " granuloma," and from it a pure 
cultivation of staphylococcus pyogenes aureus was obtained. 
They are probably always the result of suppuration, and are 
really only exaggerations of what used to be popularly called 
" proud flesh." The following are examples : A moist cherry- 
red tumor, the size of a large pea, developed on the palm of a 
lady following suppuration. It was cured by ligature. Another 
was a tumor the size of half a walnut just below the knee, 
bright red and lobulated. It developed on a dermatitis, took 
three years to get as large as a raspberry and one more to 
reach the above size. It was excised under the idea that it was 
sarcoma, but on account of its age was composed largely of 
fibrous tissue. The idea entertained by Dor, Spick, and other 
writers that botryomyces are the real pathogenic agents is, I 
believe, quite erroneous. Pus cocci are undoubtedly present 
and quite sufficient to account for the lesion — a view I am glad 
to find held also by Sabrazes, Laubie and Jaboulay, and Bodin.f 

*" Botryomycosis humaine," Congres de Chirttrg. de Paris, October, 
1897; and good abs. in Brit. Jour. Derm., vol. x. (1898), p. 209. 

f " Botryomycose humaine," E. Bodn, Annates de Derm., vol. iii. (1902), 
p. 289. 



io82 DISEASES OF THE SKIN. 



GRANULOMA ANNULARE.* 

Definition. — A disease characterized by an aggregation of 
nodules or papules into a ring, which enlarges peripherally 
while it involutes centrally. 

In 1893 I described the first recognized case of this disease 
as a case of lupus erythematosus which resembled lichen planus; 
since then I have had four other cases; Pernet, while acting 
for me, has recognized another, Pringle f and Sequeira each 
have shown a well-marked case to the Dermatological Society 
of London. These are all the cases I know of, unless lichen 
annularis is found to be the same disease. 

The lesions occur chiefly about the wrists and hands, but also 
on the neck, especially the nape, where in the form of papules 
they have been present in four out of the eight recorded cases 
(three of mine and Pringle's case); the elbows and knees (one 
case); behind the ears, the face (one case), and near the border 
of the hair are less usual positions. 

The most striking feature is the formation of rings made up 
by the aggregation of nodules from a millet to a hemp seed 
in size; these, although partially coalescing, nearly always re- 
main recognizable as the component elements of the ring. The 
ring is oval or round, and clears in the center while it enlarges 
peripherally; sometimes part of the border also involutes and 
leaves a crescentic lesion with the concave portion sloping down 
into the normal skin. The center may be slightly reddened, 
normal, or slightly atrophic; the border raised from a sixteenth 
to an eighth of an inch above the surface more or less distinctly 
nodular, abrupt on the outer, sloping on the inner surface, and 
firm to the touch. The color may be deep red, pale red, or 
almost white, with a narrow red or violet areola. The surface 
may be slightly scaly, or corrugated, or even warty-looking 
(Pringle) to a slight degree, and one of my patients had had 
numerous warts on his hands, another had a single wart. The 

* Amer. Jour. Cut. and Gen.-Ur. Dis., vol. xii. (1894), p. 1, with colored 
plate. Reproduced in my Atlas, Plate LXVIL, Figs. 1 and 2, together 
with a brief note of another case. Other cases are published under the 
name now employed in the Brit. Jour. Derm., vol. xiv. (1902), p. 1, with 
colored and histological plate. 

f Pringle, Brit. Jour. Derm., vol. xi. (1899), p. 435. 



GRANULOMA ANNULARE. 1083 

suggestion of a form of lupus erythematosus struck me at first 
in some of the cases, and Pringle compared some of the lesions 
to those of lichen planus, to which I had also called attention. 

The disease usually commenced as a nodule or aggregation of 
nodules, one patient described a mattery head on some of them, 
and the number of plaques was from one to about a score in 
different cases. The development was slow, varying from 
months to years; my first case was of four years' duration, my 
last six months, but some lesions involuted spontaneously. 

In the oldest woman, who had a strong tubercular history, the 
single patch on the wrist gradually changed its character, and 
developed into what appeared like a lupus verrucosus, which 
was nearly cured with salicylic acid plaster. She had a single 
nodule on the nape close to the hair. In the boy of eleven the 
lesions were only on the wrists and elbows and knees. On the 
right elbow, instead of a ring, there was an irregular aggrega- 
tion of discrete pale purplish-red papules; there were some 
similar papules on the right knee and a ring undergoing involu- 
tion; on the left knee a ring had gone, leaving only a red stain. 
This boy had a common wart on one palm. 

In Pringle's case the neck, face, scalp, and back of the right 
wrist were affected, in the latter as a band of flat angular 
papules, like verrucas planse. There were also numerous dis- 
crete papules disseminated over the forehead and scalp; the 
patient had some also at the nape. 

Etiology. — Seven were males, six between twenty and forty 
and one eleven years of age. One was a female, set. fifty-two. 

In one of my cases there was a strong family history of 
phthisis, in another they were said to have weak chests. In one, 
set. eleven, the father was very gouty. In others there was no 
evidence of disease in themselves or their relatives. My fifth 
case was a gentleman, set. thirty-four; he was positive that it 
began as a cut which he picked. It had been present four 
years.* 

Pathology. — I have microscopically examined a papule from 
the nape of my first case, and found that the greater part of 
the papule was made up of a dense mass of cells, the chief por- 

*The case is published in Brit. Jour. Derm., vol. xiv. (August, 1902), 
p. 307, as the seventh case. Sequeira's, the eighth case, was shown after 
my report was sent in, and is published in the July number, p. 270. 



1084 DISEASES OF THE SKIN. 

tion of which was situated between two hair follicles, which 
were, however, partially embraced by the cell mass. There was 
very little increase of the horny layer, but the prickle cell layer 
was enormously thickened, and in one section it appeared to be 
prolonged in the course of a sweat duct. The papillae were quite 
obliterated in the central portion, but not at the periphery, 
where they were broader but shorter. Beneath the cell mass 
was a sweat-coil showing cell infiltration round it, but, traced 
upwards it entered the cell mass, which was almost con- 
fined to the superficial part of the corium. At the side there was 
a small amount of cell exudation about some of the hair follicles 
away from the main papule, but it was not very marked. The 
sections were made several years ago, before differential stain- 
ing, to show the nature of the component cells, was in vogue. 

Quite recently * I have examined a nodule from the skin over 
the second knuckle about a quarter by one-eighth of an inch. 
It presented quite a different picture from the above nape 
nodule, and was much more like the histology of Galloway's 
case of lichen annularis, and induces me to admit the probable 
identity of the two affections. Vide p. 456. 

The histological changes were most marked in the deep layers 
of the corium. In most of the sections the cell infiltration in 
the papillary layer, and immediately below it, was very scanty, 
but in the one illustrated, probably from the center of the 
nodule, the cell infiltration reached quite up to the epidermis. 
The cells were not massed together, as in the nape nodule, but 
in small clumps round the vessels, and were most abundant 
round the sweat coils. They were apparently a mixture of con- 
nective tissue cells and leukocytes. The vessels were dilated, 
the prickle cell layer was much thickened, and so was the corne- 
ous layer, but to a smaller extent. It will be noted that the 
center of the nodule was in the line of a sweat duct, and the 
general aspect was that of a chronic inflammation round the 
sweat coil and duct. The primarily deep seat of the inflamma- 
tion is unlike any form of lichen. At the same time this nodule 
does not suggest a granuloma. 

Clinically the extreme indolence of the disease, many of the 

* August, 1902. After this article had gone to press I obtained a nodule 
from my last case, and the sections were made from the fresh tissue. A 
more detailed examination will be made later on. 



GRANULOMA ANNULARE. 



1085 



lesions remaining for years with scarcely any change, show- 
that it is no ordinary inflammation, and its circinate character 
and unsymmetrical distribution on exposed parts suggest a mi- 
crobic origin. 

Dubreuilh found the epidermis almost unaltered. In the mid- 
dle of the dermis there was a focus of cellular infiltration, while 




- -: - ;.;'■ 



■Bno 




t "* ! ^Ii 



Fig. 63. — Papule from nape, showing, a, dense cell mass in the papillary 
layer of the cutis; b, increased thickness of prickle cell layer; c, 
unaltered horny layer; d, portion of hair follicle and sebaceous gland. 
X Ross 1 in. 16 in. tube. 

the superficial part of the cutis, papillary layer, and the diffuse 
part including the sweat glands, were quite free. 

The cells were infiltrated between the bundles of connective 
tissue, but this and the elastic tissue were unaltered. The cells 
he considered to be connective tissue cells. There were no 
giant cells and but few mast cells. 

Diagnosis. — The disease it most resembles is lichen annularis. 
In both there are ringed lesions with crenate borders which 
occur on the hands; both are nodular and begin as nodules. 
Granuloma annulare is much more distinctlv nodular through- 



io86 



DISEASES OF THE SKIN. 



out its course, and begins from an aggregation of a group of 
nodules, while lichen annularis starts from a single nodule and 
spreads into a ring, and in a fully-formed ring the nodular 
origin is obliterated. Probably this difference in the mode of 
origin is one of the most distinctive features, but the histologi- 
cal resemblance in the granuloma and lichen annularis cases of 
the lesions from the hands seem to outweigh the differences, 
and their pathology is probably the same in spite of the great 
contrast presented by the nape nodule. It must be admitted 
that the histology of the Dubreuilh case, judging from the de- 




V 




S / 



Fig. 64. — Nodule of granuloma annulare from knuckle, a, thickened 
corneous layer; b, thickened rete; c, sweat duct; d, dilated vessels; 
e, cell infiltration, most marked in subpapillary layer;/", sweat coil 
with dense cell infiltration. 

scription, does not correspond with either Galloway's or my 
sections. 

Treatment. — The most effectual treatment is the application 
of a mercurial plaster; the Beiersdorf 255 paraplast, which also 
contains carbolic acid, is one of the best. The lesions slowly 
disappear with this, and occasionally some of them involute 
spontaneously, but, as already seen, this is exceptional, the 
disease lasting for years if not treated. 



CLASS VIII. 

MORBI APPENDICIUM— DISEASES OF 
THE APPENDAGES. 

A.— DISEASES OF THE SWEAT GLANDS. 

Affections of the sweat glands are " functional," in which 
the quantity or quality of the secretion is altered, and " or- 
ganic," due to obstruction of the duct; the latter may be non- 
inflammatory, as in sudamina, or with inflammation in or 
around the sweat apparatus, either primary, as in miliaria 
papulosa, or secondary to the obstruction, as in miliaria vesic- 
ulosa. Hydradenitis, or inflammation of the sweat coil, is de- 
scribed along with furunculi. Pompholyx or dysidrosis and 
lichen planus, both of which have, in my belief, their seat in or 
about the sweat apparatus, are described among the general 
inflammations of the skin, as this view is not generally ac- 
cepted. There are certain forms of eczema and psoriasis in 
which the primary lesion appears to be situated in and about 
the sweat pore, and Mibelli's porokeratosis is named on the 
belief in a similar connection. Arsenical keratosis of the palms 
and soles also commences at the sweat pores, and probably the 
keratoses in connection with hyperidrosis have the same 
starting-point. 

HYPERIDROSIS.* 

Deriv. — vnep, super; id poo?, sweat. 

Synonyms. — Excessive sweating; Idrosis; Ephidrosis; Sudatoria. 

Definition. — A functional disorder of the sweat glands, in 
which the secretion is excessive. 

Hyperidrosis may be general or partial, slight or severe, 
acute or chronic. 

Universal sweating may be symptomatic, as in acute rheuma- 

* Literature. — " Des sueurs morbides," by L. Bouveret (Paris, 1889). 

1087 



io88 



DISEASES OF THE SKIN. 



tism, phthisis, hectic fever, ague, rickets, or the so-called 
" sweating sickness " of the Middle Ages, etc., but it is only 
with those forms which are apparently idiopathic that we have 
now to do. 

Symptoms. — The sweat is often quite cold, and, when general, 
is not very excessive, except in rare instances, when it may be 
so great as even to be fatal.* The local forms may be para- 




Fig. 65. — A Normal Sweat Gland, highly magnified (Neumann). 
a, sweat coil with secreting epithelial cells; b, sweat duct; c, lumen of 
duct; d, connective tissue capsule; e and f, arterial trunk and 
capillaries supplying the gland. 

plegic f or hemiplegic in distribution, or symmetrically local- 
ized to certain regions, especially the palms, soles, axillae, and 
genital regions; and when in these hot covered parts, is often 
associated with bromidrosis. 

Unilateral cases affecting the whole of one side of the body 
are rare; it is more often confined to one side of the head, in 

* Myrtle of Harrogate, in Med. Press, February 25, 1885, relates the 
case of a man, set. seventy-seven, who, after some flying pains and fever, 
began to sweat profusely, and continued to do so until he died exhausted, 
in three months from the onset of the sweating. Richardson, in the 
Asclepiad, vol. for 1885, p. 191, records another such case, and one of hemi- 
erythema followed by profuse hemi-hyperidrosis. 

|S. Mackenzie, upper half of body affected, Clin. Soc. Trans., vol. 
xviii., 1884. 



HYPERIDROSIS. 1089 

the domain of the fifth nerve,* or to one limb, or portion of it, 
e. g., the ulnar nerve, but even these limited cases are not 
common. There is usually a bright erythema of the part af- 
fected preceding and accompanying the hyperidrosis. 

The palms and soles are very frequently attacked, either to- 
gether or separately, and there are all grades, from merely 
moisture to profuse dripping in severe cases. If on the hands, 
it disables the patient from social duties or from many occupa- 
tions, and may lead to keratosis; and if on the feet, it interferes 
with walking, the skin becoming sodden, corrugated, and in 
parts red and tender, or the epidermis may be enormously 
thickened on the points of pressure. In two cases, one on the 
palms, the other on the soles, I have seen a very superficial 
erosion of the epidermis commencing round the sweat orifices. 
In the palm case the black from his work outlined the borders 
of the erosions. In regions like the genitals, in contact with 
adjacent surfaces, intertrigo and eczema may arise. The sweat- 
ing may be continuous or intermittent, aggravated when the 
-weather is hot, or under emotion, or depression of the general 
health, and in the domain of the fifth is often excited by mas- 
tication. It may be temporary or permanent, and last for weeks 
or years. 

Etiology. — Neither sex, age, nor social condition has any influ- 
ence on its production. Faulty innervation is probably the 
main cause, but we can rarely detect the starting influence which 
produced the effect. In several instances of localized unilateral 
sweating there has been suppuration, presumably involving the 
nerve supply of the part, e. g., suppuration of the parotid fol- 
lowed by sweating of the face of the same side, or bubo fol- 
lowed by inguinal sweating. In other cases there has probably 
"been an undetected neuritis, which possibly may, in some in- 
stances, be gouty. In slight degrees, e. g., in the palms, it is 
often congenital, and in rare instances, hereditary, or it may 
be vicarious, as in local sweating, e. g., of the palms in 
ichthyosis. 

Pathology. — Claude Bernard's experiments showed that sec- 
tion of the sympathetic was followed by hyperidrosis, and 
Brown-Sequard's, that excitation of sensory nerves would pro- 

* Bril. Jour. Derm., vol. iii. (1891), p. 357, a case in Unna's clinic; the 
center of the face was affected, especially the tip of the nose. 

• 69 



1090 



DISEASES OF THE SKIN. 



duce sweating. In a case of Traube's profuse sweating came 
on a few days before death, and at the post-mortem a tumor 
was found in the cord, half an inch below the medulla oblongata. 
Weir Mitchell describes localized sweatings after division of 
a nerve by gunshot injuries, etc. These facts lead to the infer- 
ence that injury or disease, which directly or indirectly inter- 
feres with the function of the sympathetic of the affected 
region, is the proximate cause of the excessive secretion. The 
fluid itself is normal in its constituents. A case of profuse post- 
mortem sweating some hours after death is recorded by J. A. 
Cones.* 

The prognosis is variable, and there are seldom data to enable 
an opinion to be formed. 

Treatment. — Careful investigation into the general health 
should be made and any defect rectified. Success is more hope- 
ful in acquired than in congenital cases. The mineral acids and 
nux vomica suit many cases where there is debility; iron, 
quinine, and cod-liver oil are often indicated. Failing any gen- 
eral indications, certain special remedies may be tried. The 
tincture of belladonna pushed to the physiological limit is often 
useful, probably as a vaso-motor stimulant; or hypodermic in- 
jections of atropia might be tried, 1-150 of a grain increased 
up to 1-60; 1-6 grain of agaricin is much praised by Piering. 
I have found ergot in full doses, such as 5ss or more of the 
liquid extract three times a day, answer well for some cases; 
but the best of all, in my experience, is sulphur. A level tea- 
spoonful of the precipitated sulphur in milk twice a day is the 
usual dose. Where it purges too much it may be combined 
with astringents, as in the following: pulv. cretse co. 5vj, pulv. 
cinnam. co. oij, sulph. prsecipit. §j; a teaspoonful to be taken 
twice a day. What its modus operandi may be I am not prepared 
to say, but it has succeeded more often than anything else in my 
hands, and local treatment is not required, as a rule, with it.f 
Krahn says that sage is a powerful antihidrotic remedy; fifty 

* Lancet, May 25, 1889. 

fin Penwarden, U. C. H., a tailor, set sixty-five, hyperidrosis had ex- 
isted thirty-five years. It was usually confined to the hands and feet, 
but at its worst affected the whole body. It was absent as long as he 
preserved the horizontal posture, but came on directly he got up, and 
was always increased in the summer months. When at its worst he lost 
appetite and spirits, had a pricking sensation, and sometimes minute red 



HYPER1DR0SIS. 



1091 



grains of sage leaves to a pint of hot water makes an infusion, 
of which a teacupful may be taken three times a day, or a tinc- 
ture can be made. 

Acetate of thallium was strongly advocated for the night 
sweats of phthisis, etc., but as it produces total alopecia in a 
few days it is only mentioned as a warning against it. 

Local treatment is often of great assistance. Faradizing the 
part has sometimes been successful, but belladonna ointment or 
liniment rubbed in is one of the best remedies. For the feet, 
Hebra's * plan, which he said was always successful, was to keep 
them closely wrapped up, each toe separately, in an ointment 
of ung. lithargyri, changed twice a day, and the treatment con- 
tinued for a fortnight; others recommended oxid of zinc oint- 
ment. These methods are too cumbersome, necessitate lying 
up, and are therefore generally impracticable, while it is by no 
means always successful even in acquired hyperidrosis. Duffin's 
modification of strapping the feet is better, as it allows the pa- 
tient to go about; it should be done evenly and firmly, with 
stout lead or soap plaster. Thin's plan is to dredge boric acid, 
very finely powdered, into the stockings and boots every day, 
and to put in the boots cork socks, which should be washed 
and disinfected in boric acid lotion daily. This is cleanly and 
convenient, and one of the best methods of local treatment. 
Tartaric acid (Frederique) and subnitrate of bismuth may be 
used in the same way, or rubbed over the body when the hy- 
peridrosis is general. 

Painting the soles with a three per cent, solution of formalin 
is recommended by Gerdeck to be used three times a day. 

When it is desired to check sweating in the axillae or elsewhere 
for some hours, holding a very hot sponge to the part for a 
few minutes is effectual. A powder of three per cent, of sali- 
cylic acid may also be dusted on, and sponging on one per cent. 
of quinine in alcohol is recommended by Fox of New York. 

Astringents, such as one or two per cent, of alum and tannin 
in alcohol, are also employed, and are useful sometimes. 

Disinfectant soaps, such as terebene, carbolic acid, and daily 

papules appeared all over the hands. He had tried almost every variety 
of treatment, but, of all, sulphur internally did him most good, keeping 
the disease under for twelve months; but latterly, even that failed. 
*See Formulae: Ointments, No. 10, Ung. Diachyli. 



1092 DISEASES OF THE SKIN, 

ablutions, are adjuvants. Many other remedies are recom- 
mended, but there are none better than sulphur internally and 
boric acid or borax locally. 

BROMIDROSIS. 

Deriv. — fipoopios, a stench. 
Synonym. — Osmidrosis. 

Definition. — Offensive sweating due to functional disorder of 
the sweat glands, or to alteration of the sweat after its 
excretion. 

Symptoms. — It may be symptomatic, as in rheumatic fever, 
scurvy, syphilis, scrofula, uremia, or after certain ingesta, etc., 
or idiopathic. There is generally hyperidrosis, but sometimes 
the quantity is normal. It may be local or general; the local 
is the most common, affecting the feet only, but the axillae, 
groins, and perineum may also be involved. 

When affecting the feet, the odor is, sui generis, most pene- 
trating and nauseous, and once smelled will not be forgotten: 
perhaps putrid cheese is the best comparison. The sufferer is, 
therefore, unfitted for society and indoor occupations. The 
stockings and boots are soaked with the evil-smelling fluid, 
and the feet sodden like a washerwoman's hands; often there 
is secondary redness, especially at the borders, much tender- 
ness, and sometimes blebs are formed and walking then becomes 
impossible. 

In other parts of the body the odor is different, and usually 
not so strong, except in the axillae, where the natural odor is 
much exaggerated in some persons. 

In certain nervous states, and in a few persons from idiosyn- 
crasy, pleasant odors of the sweat have been noticed, such as 
that of violets, musk, and pine-apple, and one of Hammond's * 
cases was also unilateral. Weir Mitchell has observed that in 
lesions of the nerves the corresponding area exhales an odor 
like that of stagnant water. 

Etiology. — Local bromidrosis is generally observed in young 

* W. A. Hammond, "On Odors in Connection with the Nervous Sys- 
tem," New York Med. Rec, vol. xii. (1877), P- 4 6 °i an d Monin, " Sur les 
odeurs du corps humain " (Paris, 1885); full abstract in Amer. Jour, of 
Cut. and Ven. Dis., July, 1885, p. 211. 



HYPERIDROSIS. 



1093 



people and in the feet; it is most common in domestic servants, 
or others who have much standing. Some cases are due to 
emotional conditions, while the causes of others are quite ob- 
scure. Race has a distinct influence. Thus the negro and China- 
man has each a special odor disagreeable to other races, while 
the Chinese say we are equally objectionable to them. 

Pathology. — As Hebra pointed out, the sweat of the feet is not 
offensive when first secreted, and Thin's investigations point to 
its becoming so from the presence of micrococci. These under 
cultivation develop into bacteria, which he calls bacterium 
fetidum. Moore, the botanist, thinks this bacterium is identical 
with that found on surface soil which reduces nitrates, sulphates, 
and phosphates into nitrites, sulphities, and phosphites. The 
micrococci may be readily seen if some of the sweat be dried 
on a cover-glass and stained with methyl violet. Similar 
micrococci can generally be found between the toes even with- 
out bromidrosis, getting there probably with dust. 

Treatment. — Thin's plan locally, and sulphur internally, as 
described under hyperidrosis, is the most convenient and ef- 
fectual treatment. The sulphur alone is generally sufficient. In 
the German army, rubbing the feet with mutton suet with two 
per cent, of salicylic acid is almost universally adopted, and 
where there is much walking, has the advantage of lubricating 
the feet. Latterly, a five per cent, solution of chromic acid, 
painted on the feet every three to six weeks, has been success- 
fully employed. In very obstinate cases ten per cent, may be 
used; a two or three per cent, formalin solution has many 
friends. Salicylate of sodium in five to ten grain doses has 
cured some cases. For other methods see Hyperidrosis. 

CHROMIDROSIS.* 

Deriv. — xP^M a ; color, and ISpGoS, sweat. 

Synonyms. — Stearrhea or Seborrhea nigricans (Wilson and 
Neligan); Pityriasis nigricans (Read). 

Definition. — Colored excretion of sweat or sebum. 

Symptoms. — The first case of this very rare and curious affec- 
tion was published by Yonge of Plymouth in 1709. In it col- 

* Literature.— Author's Atlas, Plate LXXIX. Le Roy de Mericourt, 
14 Memoire sur la chromidrose " (Bailliere et Fils, Paris, 1864). Wynne 



1094 DISEASES OF THE SKIN. 

ored sweating appears symmetrically distributed in various parts 
of the body, but chiefly about the orbital region, affecting the 
lower lid more than the upper; the other parts commonly in- 
volved, in the order of frequency, are the cheeks, forehead, side 
of the nose, while the whole face, the chest, abdomen, backs of 
the hands, finger-tips (once), and the flexures, as the axillse, 
groins, and popliteal spaces, are more rarely affected. The 
color is usually black or sepia, but may be blue from azure to 
indigo; red, green, yellow, and violet sweats have been re- 
corded, and in some cases the color has changed while under 
observation, as from blue to black, blue to ochreous, yellow 
to black. In Purdon's case it was light blue on the back and 
once on the chest, and yellow on the abdomen and back of the 
neck occurring simultaneously. The blue secretion was pre- 
ceded for twelve hours by a moldy smell and a pricking sensa- 
tion. The catamenia were reddish-green. 

It appears either rapidly or gradually, forming a powdery or 
granular deposit on the skin, which is wiped off with some 
difficulty with water alone, but is easily removed with spirit 
of chloroform, ether, or glycerin. In four cases * I have seen 

Foot, Dublin Jour, of Med. Science, August, 1869, and December, 1873, 
Roy. Acad. Med., Ireland, December 14, 1888; and Irish Hosp. Gaz. y 
February 16, 1874; also Fox's case and Report of Committee, loc. cit. 
Purdon's case, Jour, of Cut. Med., October, 1868, p. 247. 

* One of the cases, Kate L., is reported by Colcott Fox, in Clin. Soc. 
Trans., vol. xlvi., 1881. It was referred to a committee— S. Mackenzie, 
Cavafy, Fox, and myself — for investigation, and was admitted into 
U. C. H. The committee were convinced of its genuine character, on 
one occasion having seen a slight but decided renewal of the pigmenta- 
tion while in a Turkish bath. The pigmentation formed slowly. The 
report of the committee, detailing the tests employed, is published in vol. 
xv. of the Transactions. Another case reported upon at the same time 
was clearly proved to be an imposition. I have since seen another case 
at Shadwell, a woman, set. forty-seven, of naturally dark complexion; 
the bowels were habitually confined, going three or four days at least 
without an action, and latterly she had suffered from articular pains. 
The discoloration came out gradually, beginning at the sides of the face, 
then spread to the cheeks and forehead. When seen, the upper half of 
the forehead, the temporal regions, and the skin between the ear and 
malar eminence, were of a blackish-brown color, with slight hyperemia 
of the adjacent parts; she said it had been almost black, but she had 
cleaned some of it off. There was evidently much fat in the secretion, 
and there was seborrhea of the scalp. Washing with soap and water 



CHROMIDROSIS. 



i°95 



it was largely composed of fat, and was flaky or granular, and 
much more resembled seborrhea than sweating, and for these 
cases Wilson and Neligan's name, stearrhea nigricans, is more 
suitable. In other cases, such as those of Lecat, Billard, 
Bousquet, and Elliotson, etc., it seems to have been indubitably 
sweat, for it was actually seen to be excreted under observation. 
So also was the case of a child, set. ten years, in which blue 
sweat was secreted from the whole of the nose, except where 
there had been an excoriation which was apparently the exciting 
cause. Irregular crystals soluble in chloroform were obtained 
and Gecheline,* the reporter, thought it was indigo. 

It would thus seem that there are two forms — the sweat 
and the sebaceous ; and probably the first is that where it forms 
rapidly, and the last gradually. In Fereol's case f neither sweat 
nor sebum was observable. 

In a large number of cases there is obstinate constipation. 
The amount of pigmentation varies on different days, or, when 

had very little effect, but it was removed with ether, when the skin still 
looked darker and redder than the rest. After a week's treatment with 
saline purgatives the discoloration was much less, but she still had artic- 
ular pains, for which alkalies were prescribed, and she did not attend 
again. A third case was a girl, :et. twenty, originally under Mackay of 
Brighton. The affection had lasted a year, and was limited to the left 
cheek and eyebrow. Six months before the patch appeared she had a 
superficial burn, which did not leave a distinct scar, but the surface was 
slightly granular. The deposit was distinctly fatty, evidently seborrheic, 
and of a sepia tint. She suffered from obstinate constipation, the bowels 
only acting once a week. The left side flushed more than the right. In 
connection with this case may be mentioned those of Conrade, who had 
a case of blue perspiration of one-half of the scrotum; and of White of 
Harvard, a case of unilateral yellow chromidrosis in a man, Amer. Jour. 
of Ctit. and Ven. Dz's., vol. ii., November ro, 1884. I have also had a 
•case of yellow seborrhea in a lady of eighteen, sent to me by Dr. Cook of 
Cardiff. No hysteria, no constipation was present, no cause was ascer- 
tained. There was a yellow, almost orange, fatty layer extending over 
the forehead, cheeks, and orbits, shading off gradually from above down. 
It could be cleaned off with ether, but with some difficulty. It took 
two days to re-form sufficiently to be unsightly. The patient never ate 
butcher's meat. Scalp rather scurfy. Two months later there was no 
change, but in five months she was almost well. 

* The patient was shown to the Medical Society of Odessa, and is re- 
ported in Annales de Derm, et de Syph., vol. v. (1894), p. 718. 

f La France medicale, August 20, 1885. 



1096 DISEASES OF THE SKIN. 

it forms rapidly, at different times of the day. It is worse 
sometimes just before a catamenial period, and better just after 
it. It may go on for an indefinite period if the disordered 
health is not rectified, coming out and disappearing somewhat 
capriciously, and return of the constipation is very likely to 
induce a return of the disordered coloration. When checked 
in one place it has appeared in other parts of the skin and in 
the excreta; in Teevan and Brodie's case* there was black 
pigment in the vomit, feces, and urine. Billard's, Law's, and 
Neligan's cases are other examples of similar occurrences, and 
in the case of Maker of Colmar the saliva also was sometimes 
blue. Blue pus, blue urine, green and red milk have been 
observed on various occasions without chromidrosis. 

Dubreuilh observed a case, a man of fifty-two, who had three 
attacks of red chromidrosis on the radial border of the thumb 
and metacarpal bone on each side, and afterwards on the bend 
of the wrist, and Sabraze's and Cabannes' case was a man, set. 
twenty-one, in whom red chromidrosis appeared after violent 
exercise, sometimes on the back of the right hand, sometimes, 
on the left knee. They found a large quantity of indican in 
the urine. Barie's case,f a woman, aet. twenty-four, was yellow 
alternating on the two hands. The red sweat of the axillae is 
a different affection. 

Etiology. — Only eight out of forty-nine cases were in males, 
and although the ages have ranged from fifteen to fifty-seven,, 
most (two-thirds) of them have been in young unmarried 
women. Uterine disorder has been present in many cases, but 
chronic constipation is the most frequent concomitant. The 
neurotic temperament is the greatest predisposing cause, and 
mental distress, hysteria, hypochondriasis, anxiety, grief, fright, 
have preceded or accompanied the attack in different instances. 

Pathology. — The theory put forward is that the substance 
secreted in the sweat is the colorless indican, which is oxidized 
by exposure to the air or by some ferment into indigo; the 
chief ground for this theory being that in great meat-eaters and 
in constipation and chronic catarrh of the intestine, which is 
so common in these cases, indican supposed to be derived from 
the indol of the feces is more abundant in the urine than usuaL 

* Medico-Chirurgical Trans., 1845, v °l- xxviii. 
f Loc. cit., vol. x. (1889), p. 937. 



CHROMIDROSIS. 1097 

The pigment in the case of Kate L. was in amorphous granules 
in the epithelium, and did not give the indigo reactions. Dif- 
ferent opinions have been expressed as to the nature of the 
pigment, but all agree that it differs from any of the other 
mineral or vegetable powders of like color. Primarily the dis- 
ease is doubtless a neurosis, and the clinical evidence points to 
the possibility of the pigment being excreted by either the 
sweat * or the sebaceous glands. In many of the cases the 
secretion is too rapid for it to be of bacterial origin, but Stott f 
reports two cases, father and son, who had pink sweat which 
stained the shirt at the collar, wrists, and tails, but the axillae 
were unaffected. He succeeded in cultivating a torula, which 
varied from pale pink to red, according to the temperature of 
the tube — the lower the temperature the deeper the color. 

Diagnosis. — The possibility of imposition must always be 
borne in mind. The circumstances under which it occurs will 
often give a clew. There is nothing but imposture which at all 
resembles this affection, and this circumstance makes many peo- 
ple skeptical as to its genuine character; but the case of 
Teevan, Duval, Foot, Fox, etc., in all of which competent wit- 
nesses saw it reappear, prove its reality. 

Prognosis. — It ultimately always gets well, though it may last 
off and on for ten years. Kate L.'s case lasted five years at 
least, the other case two months. Its duration depends on the 
removability of the cause. 

Treatment. — The successful treatment of the constipation, 
uterine derangement, or other defective health, is the only 
efficacious treatment; local remedies appear to have had no 
influence in most cases, but in my fourth case with yellow sebor- 
rhea a resorcin and spirit lotion locally, and the administra- 
tion of salol internally, appeared to be the remedial agents after 
five months. 

Colored Sweating, with quite a different pathology, has been 
also observed under the following circumstances: 

* If Meissner's and Unna's view is correct, that the coil of the sweat 
gland secretes fat and the end of the duct sweat, disorder of the coil 
glands would account for the whole, and it would not be necessary to 
assume the involvement of the sebaceous glands. 

\ Lancet, February 15, 1896, p. 413. In the following week magenta 
sweating in a man is recorded. 



1098 DISEASES OF THE SKIN. 

i. Green Sweat, due to copper,* which has been taken into 
the system by the food, drink, or air, in particles or fumes, is 
seen mainly in copper-workers. The color may be bluish instead 
of green. In Kollman's case of blue chromidrosis, where the 
patient had taken much iron, Scherer found protosulphate of 
iron in the sweat, and to this the color was ascribed. 

2. Red Sweat is often noted in the axillae and genital region, 
due to micro-organisms, f which have developed in the hairs in 
these hot, moist parts, and have simply mingled with the sweat 
after its excretion; according to Babes % these organisms resem- 
ble not only the red bacterium prodigiosum, but colorless 
growths of the hair and sweat. Red sweat is always associated 
with leptothrix, to which the reader is referred. Bacteria have 
also been observed in yellow (Eberth) and blue sweat. 

Quite another kind, again, of red sweating is: 

3. Hematidrosis, or Bloody Sweat, sometimes called ephi- 
drosis cruenta. § It may be defined as a purpura of the sweat 
glands, blood having been extravasated into the coils and ducts, 
and appearing mixed with sweat on the surface of the unbroken 
skin, at the orifices of the ducts. 

The affection is a very rare one, and in some of the cases has 
been due to vicarious menstruation, or it may occur in young 
women of highly nervous temperament during violent emotion, 
and occasionally in the newborn. | It comes from limited areas, 
very diverse in different cases, e. g., from face, ears, umbilicus, 
hands, feet, etc. Du Gard, quoted by Wilson, records a case, 
fatal on the sixth day, in a child of three months, where it 
came in large quantities from various parts of the body. The 
notorious case of Louise LateauT with "bleeding stigmata" 

*A number of cases are recorded by Dr. Clapton, Med. Times and 
Gaz., vol. i (1868), p. 658. 

f Balzer and Barthelemy, Ann. de Derm, et de Syph., June, 1884. 

%Centralblatt. fur vied. Wissensch., 1882, p. 146. 

§ McCall Anderson, " Lect. on Clin. Med." (London, 1877). 

|| These and other hemorrhages which occur in the new-born, e. g., 
into the skin and alimentary canal, are probably due to the great changes 
which occur in the circulation after birth. 

% Warlomont, " Louise Lateau," Rapport med. (Paris and Bruxelles, 
1875). "La Stigmatisee de Bahia," Le Mouvement Med., No. 1, 1877, 
quoted by Duhring. 



URIDROSIS. 



1099 



was of this character in a highly hysterical subject, and there are 
like cases on record. 

Nevins Hyde * reports a curious case in an emotional clergy- 
man, but the bona fides of the patient was not above suspicion; 
but J. Dyer's case f was in an attendant at a Turkish bath, and 
his fellow-attendants had seen it appear and wiped it off; the 
skin was reddened before and after an attack, which lasted an 
hour. 

The treatment would depend entirely on the cause; the hemor- 
rhage itself would rarely require special treatment, but if it did 
it would be the same as for purpura hsemorrhagica. 

PHOSPHORESCENT SWEAT 

is a curious rarity. It has been observed in some cases of 
miliaria and after eating phosphorescent fish, while Koster J 
records a case where the body linen became luminous after any 
violent exertion. § Phosphorescent breath in phthisis, in the 
pus of cancer, and in the urine and semen, when phosphorus 
is being taken as a medicine, are better known. There is strong 
reason for believing that the phosphorescence is due to bacilli, 
Beyerinck || having found no less than six species of photobac- 
teria, chiefly derived from fish, which will excite fermentation in 
sugar solutions in the presence of oxygen and peptone. 

URIDROSIS.! 

Synonym. — Sudor urinosus. 

This is due to excretion of urinary constituents, especially 
urea and chlorids, by the skin. Urea is a constant constituent 
of the sweat in small quantities, but in disease may increase so 
much that white crystals, like hoar frost, have been deposited 

* Amer. [our. Cut. a?id Gen.-Ur. D/s., December, 1897. 

+ Medical News (U. S.), June 22, 1875. 

% Quoted in Carpenter's " Physiology," seventh edition, 1869, p. 500. 

§ See Sir Herbert Marsh on the evolution of light from the living human 
subject (Dublin, 1842). 

|| Supplement Brit. Med. Jour., January r, 1891. 

1" A case of Uremic Uridrosis by Frederick Taylor, Guy's Hospital 
Reports, vol. xix. (1874), p. 405, refers to several other cases. 



noo DISEASES OF THE SKIN. 

on the body. This was possibly the nature of the deposit on 
the skin of four young natives in Hyderabad, recorded by 
Frazer-Nash, though no examination of the deposit was made. 
As he mentions having seen several other slight cases, it is 
probably not uncommon in India, where the food is principally 
milk, fruit, coarse bread, and water. 

It has also been observed in cholera and atrophy of the 
kidneys, in uremia, and in some conditions just before death, 
even where there has been no affection of the kidneys and 
bladder. A urinous odor of the sweat in uremia is not 
uncommon. 

ANIDROSIS. 

Deriv. — a, privative, and idpcoS. 

Definition. — A disorder of the sweat glands, in which their 
function is more or less in abeyance. 

This condition exists in all grades, from slight diminution to 
complete absence, and may be local or universal. It may be 
symptomatic, as in diabetes, albuminuria, fevers, etc.; due to 
a congenital defect, as in xerodermia, though the absence of 
sebum is of quite as much importance in that disease, or in 
people who always perspire with difficulty even in a Turkish 
bath; or, again, it may be temporary or permanent from de- 
fective innervation, or torpor from general malnutrition, etc.; 
or, finally, it may be from mere clogging of the cutaneous 
orifices, from not washing sufficiently often. In many skin dis- 
eases it is absent in the affected area, as in anesthetic leprosy, 
sclerodermia, general or circumscribed (morphea), in eczema or 
psoriasis, and in diseases in which the horny layer is increased, 
but it is very rare as an idiopathic disease. Whether con- 
genital or acquired, when general it produces headache, pain- 
ful flushing, etc., if the patient is exposed to great heat. Tand- 
lau's congenital case, in addition to these symptoms, had very 
little hair anywhere, never had had any lower teeth, and only 
two incisors and two molars on the upper jaw. He had no 
nipples nor sign of breasts. The skin was smooth and thin,, 
and sections showed neither sweat glands nor hair follicles. 

Treatment. — Nothing can be done for cases of congenital 



MILIARIA. uoi 

origin, but when acquired and apparently idiopathic, efforts at 
restoration should be made by a general tonic system, and 
shampooing after warm baths, especially alkaline and vapor, 
but not Turkish baths; cold sponging may be used in the morn- 
ing, as part of the invigorating treatment. 



MILIARIA. 

Deriv. — Milium, millet. 

Synonyms. — Miliaria crystallina; Sudamina; Miliaria rubra; 
Miliaria alba; Lichen tropicus; Prickly heat. 

Definition. — An affection in which there is an obstruction to 
the sweat secretion, with or without inflammation as a cause 
or consequence. 

Symptoms. — The non-inflammatory form is called sudamina, 
or miliaria crystallina. It is simply the result of the sweat be- 
ing unable to escape, owing probably to an accumulation of 
epithelium at the orifice of the duct when the sweat function is 
in abeyance, as in fevers; then, when secretion is restored, espe- 
cially by a " critical sweating," the fluid, being unable to escape 
by the natural channel, is effused under the horny layer, and 
forms a vesicle. The vesicles are very minute, closely crowded 
together, but rarely confluent, with clear or pearly contents with 
an acid or neutral reaction; the fluid is absorbed in a few days, 
leaving slight desquamation. The vesicles occur most abun- 
antiy on the trunk, especially the neck, chest, and abdomen, 
but they may come anywhere. They form rapidly, do not en- 
large after the first few hours, and get well in a few days, unless 
fresh crops appear, which may keep up the affection for weeks. 

Miliaria Vesiculosa et Rubra. This is an inflammation in the 
sweat-pore area, and the lesions may be simply acuminate, pin's- 
point-sized, bright red papules, or crowned with vesicles or 
pustules. They arise in great numbers, chiefly upon the trunk, 
especially on the back, but may also be distributed on the face 
and limbs. They are closely crowded, but discrete, though they 
are frequently in irregular groups of three to six. and the fluid, 
being inflammatory, is of alkaline reaction. There may be a 



uo2 DISEASES OF THE SKIN. 

general redness of the skin in the affected area. When there are 
only bright red papules it is miliaria rubra; when there are 
vesicles the fluid soon becomes opaque, and it is miliaria alba. 
In a few days the contents dry up and leave slight desquama- 
tion; or if ruptured by scratching — for they do not rupture 
spontaneously — a small scab or dried exudation is left, which 
falls off in two or three days, and the process is at an end as 
far as those lesions are concerned, though by successive crops 
the eruption may continue as long as the hot weather lasts. 
Pricking or itching is often present, but not so much as in 
miliaria papulosa. 

The " red gum " * or strophulus of infants is really a sweat 
rash in small groups of miliaria rubra, due to the infant's being 
too much swathed up; it is often unilateral, on the side of the 
face and arm which is held to the mother in nursing, when she 
suckles mainly with one breast. 

I have seen a precisely similar rash in a man; it affected the 
trunk chiefly, which was thickly covered with small groups of 
papules or papulo-vesicles. He had had it ten years, and it 
came out either in hot weather or when he got hot at his work. 
Small doses of arsenic controlled it, but did not cure it. In 
another man the eruption was of the same kind, but he had been 
in the tropics. 

Miliaria Palmae et Plantae. In rare instances minute vesico- 
pustules form at the sweat orifices of the palms, dry into horny 
plaques, and shell off, leaving a depression with scaly collar. 
This may go on for years if not treated. I have also seen it in 
an acute form on the soles of an infant. 

Miliaria Papulosa, another variety of M. rubra, is the well- 
known lichen tropicus, or prickly heat, the presence of papules 
being its only title to the name of lichen. 

It differs from M. vesiculosa in the inflammation being sec- 
ondary to the retention of the sweat in that disease, while in 
M. papulosa the inflammation produces the obstruction to the 
sweat secretion. 

* Author's Atlas, Plate XLII., Fig. 2. Sydenham Society's Atlas, 
Plate XXXIV. 



MILIARIA. 



1 103 



It consists of minute, bright red, acuminate, discrete papules, 
closely crowded together, with vesicles or vesico-pustules 
sparsely interspersed. It comes out suddenly, preceded and ac- 
companied by profuse sweating in other parts, and is attended 
with intolerable pricking and tingling. It affects large areas, 
chiefly in covered parts, such as the limbs, breast, flanks, and 
upper part of the forehead; the last position is the most common 
in my experience, but in the tropics, and in people who have 
had it before, it may come anywhere. 

Miliary fever * (Synonym. — Sweating sickness) is an epidemic 
disease in which profuse sweating and miliaria are prominent 
symptoms. The first record of it was a severe epidemic in 
London in 1485; of late years it has been almost confined to the 
north of France. 

Etiology. — Sudamina are most frequently seen at the termina- 
tion of a fever, such as typhus, typhoid, acute rheumatism, 
puerperal septicemia, or in some prostrating constitutional con- 
dition, such as tuberculosis. It occurs at all ages when the vital 
powers are depressed, though the depression has only an in- 
direct effect by producing an excess of sweat beyond the ex- 
cretory capacity of the ducts. 

M. vesiculosa occurs under much the same conditions, but is 
more readily re-excited by injudicious eating, hot drinks, or 
acrid sweat and too warm clothing, as in delicate infants, and 
possibly by chills when the skin is excited by the previous 
conditions. 

M. papulosa is most common and most highly developed in 
hot climates, but is not unusual in England in the summer, 
though it is rarely intense here, unless the patient has had 
previous attacks abroad, for one attack strongly disposes to 
another, and very slight causes will reproduce it in the predis- 
posed; too warm or close-fitting clothing, or the irritation of 
flannel, are some of many exciting causes, as are also rapid 
alternations of temperature, whether from cold to hot or from 

-For a further account of it, see Ziemssen's "Encyclopedia," 1875, 
vol. ii. p. 485, and Lancet, October t, 1887, p. 671, giving the symptoms 
of an epidemic in the central departments of France in the spring of 
1887; also " Plagues Ancient and Modern: or, The Black Death and the 
Sweating Sickness," by Joseph Frank Payne, M. D. Also Kaposi- 
Besnier, vol. i. p. 165. 



iio 4 DISEASES OF THE SKIN. 

hot to cold; hence, therefore, too thin clothing may also con- 
duce to it. It is most frequently seen in obese people, or in 
those who perspire profusely. 

Anatomy. — The pathology has been sufficiently explained; the anatomy 
of sudamina has been investigated by Haight, Robinson, and Pollitzer, 
of New York,* Coats of Glasgow, and Torok. The vesicle is formed 
between the deeper lamellae of the corneous layer; the fluid in it is sweat, 
and a sweat duct is always to be found beneath the vesicle; the duct 
being obstructed, the sweat ruptures it, and is effused as described. 
Coats says that it is more than mere obstruction. There is inflammatory 
irritation of the sweat glands and ducts, and that it is leukocytic immi- 
gration which plugs the twisted part of the duct, and the epithelial cells 
are stretched and dissociated and a cavity is formed. In a case of acute 
rheumatism he found diplococci. 

The fluid from a severe case of sudamina in typhoid fever was ex- 
amined by Robinson, who found eighteen parts per thousand solid, four- 
teen organic and four inorganic matter, chiefly chlorids. No uric acid, 
sulphates, phosphates, albumin, or sugar. 

In M. vesiculosa and papulosa slight inflammatory exudation doubt- 
less occurs about the ducts, and in M. vesiculosa the inflammatory fluid 
is effused more freely than in M. papulosa. 

Robinson and Torok have both examined M. rubra. Robinson says 
that the inflammation is about the sweat pore, Torok that it has nothing 
to do with it. As they are both good observers, we must assume that it 
is not always round the sweat pore, and in this Pollitzer agrees; though 
in the majority of cases it is connected with the sweat duct, he says all 
agree that the lesion is due to inflammation starting in the papillae, and 
Robinson often observed a catarrhal condition of the sweat coil. On the 
whole, the evidence goes to show that the process is a sweat inflamma- 
tion, and the vesicles are situated in the prickle cell layer. 

Pollitzer accounts for the obstruction of the flow of sweat in prickly 
heat by a theory of the cells of the epidermis swelling by imbibition from 
the excessive sweat, owing to white skins being less oily than dark skins, 
and suggests oil inunctions after bathing, like the old Romans, as a pre- 
ventive measure. 

Diagnosis. — The minute pearly vesicles of sudamina can 
scarcely be mistaken for anything else. 

M. vesiculosa is most like vesicular eczema, but in the latter 
there is a tendency to form patches, and the vesicles rupture 

* "Miliaria and Sudamina," Amer. Jour. Cut. and Ven. Di's., vol. ii., 
p. 362, " Prickly Heat," etc , Pollitzer, loc. cit., vol. xi. p. 50, February, 
1893. "The Miliaria Group," Pollitzer, New York Med. Jour., January 
6, 1894. " The Pathology of Sudamina and Miliaria," Coats, Jour. Path., 
and " Bacteriology," October, 1892. Abs. Brit. Jour. Derm., vol. v. 
(1893), p. 221. 



MILIARIA. 1 1 05 

spontaneously, while in miliaria the lesions are scattered irreg- 
ularly, or the groups are very small and the vesicles do not 
rupture of themselves, and while each is on a red base the sur- 
face is not red, as in eczema. Miliaria is more transitory, com- 
ing in sudden repeated crops; eczema is a more continuous 
process. 

M. papulosa is most like papular eczema; its association with 
sweating, the sudden onset, and perhaps equally sudden decline, 
its occurrence only in hot weather, the peculiar pricking sensa- 
tion, and the minute size of the papules, scarcely allow of a 
mistake. 

In children these sweat rashes often suggest an exanthem; 
their localization to hot situations, the accompanying sweating, 
and the absence of the constitutional symptoms of measles, 
scarlatina, and rotheln, etc., will generally guide aright; but 
when sudamina occur with scarlatina such criteria fail, and the 
knowledge of the possibility of such a conjunction is all there 
is to afford a clew. 

Prognosis. — In temperate climates it generally yields readily 
to appropriate treatment. In hot climates it may pass on into 
an eczema or intertrigo in fat persons. Relapses are common, 
sometimes every summer. 

Treatment. — Sudamina require no treatment. In the inflam- 
matory forms, saline diuretics, such as the acetate and nitrate 
of potash, are the best remedies. In prickly heat much the 
same treatment is required; at the same time, search must 
be made for exciting causes, and rest, light clothing, and 
simple diet must be enjoined; these precautions, with saline 
aperients and lemon or lime-juice drinks soon give relief. To 
avoid future attacks care should be taken to prevent exposure 
to rapid alternations of temperature, especially chills, and 
woolen materials are therefore preferable to cotton for under- 
clothing. Locally, calamin lotion, a weak lactate or acetate of 
lead, or a very weak liquor carbonis detergens lotion (Lotions, 
F. 1,3, 38, 39, 41), may be employed. Alkaline and bran baths 
at a temperature of 90 to 95 F. often give relief. Zinc and 
starch dusting powders or finely powdered boric acid and starch 
are also useful. One of these applications should be applied 
whenever the irritation is great, so as to obviate scratching, 
which always aggravates the eruption. 
70 



no6 DISEASES OF THE SKIN. 

Cribriform pitting, or Sudamina atrophica (?). I have seen 
three cases of this rare and undescribed eruption. The first 
was a lady,* set. nineteen, in whom minute vesicles not quite 
superficial, as except with a lens they looked like normal 
colored papules, had appeared for a month past in groups of 
from three to six, and after lasting a day disappeared, and 
left minute depressions like atrophic pits or lines. They were 
situated on the cheeks and sides of the nose. 

In a girl, set. thirteen, the affection had lasted two years and 
was worse in the summer. All over the cheeks there was red- 
ness from minute telangiectic vessels, also minute vesicles sit- 
uated in the center of the tufts of the vessels which left tiny 
scarlike depressions. 

In another girl of the same age there was an even more 
marked condition of telangiectases and atrophic pin's-head pit- 
ting all over the cheeks, which had a cribriform aspect, but 
there were no vesicles while she was under observation. Some 
of the pits near the orbit were surrounded by healthy skin. The 
disease had commenced a year before in a patch on the left 
cheek. 

A fourth case was probably an allied condition, but there 
was neither telangiectasis nor scarring. She was a young lady,f 
aet. thirteen, who had had the disease four or five years. It 
was confined to the eyebrows and a large patch on each side of 
the face, and these areas were crowded with minute pin's-point 
vesicles, which collapsed on pricking. In the summer, and when 
she was hot, there was redness of the affected area. 

The presence of pitting shows that the vesicles were not 
epidermic in origin, and that they were probably situated in the 
papillary layer, but I have not, been able to follow the cases up 
and ascertain whether the pitting was permanent, probably not. 
The condition appears to be something intermediate between 
sudamina and hidrocystoma, but no histological observations 
could be made. 

C. Fox X exhibited a similar case, in a girl of thirteen years,, 
affecting the greater portion of the cheeks. There were no 
telangiectases and no comedones. With a lens minute conical 

*B. 1 88, Private Notes. 

•f-C. P., 108, Private Notes. 

JC. Fox, Brit. Jour. Derm., vol. viii. (1896), p. 220. 



HIDROCYSTOMA. 



1107 



hyperemic papules were discernible. After observing the case 
for some months he came to the conclusion that the " process 
was folliculitis with subsequent atrophy." Galloway * showed 
another case, a woman, aet. twenty-six. It came on five years 
previously, after exposure to severe cold, and affected the whole 
face, ears, and front of the neck. There was minute pitting, 
general erythema, and minute telangiectasis. He thought the 
sweat apparatus was involved. 

HIDROCYSTOMA.f 

Synonyms. — Dysidrosis of the face (G. J. Jackson and 
Rosenthal). 

Definition. — A non-inflammatory eruption, limited to the face, 
consisting of deep-seated vesicles formed in the sweat apparatus. 

The disease consists of deep-seated non-inflammatory vesi- 
cles, and was first described in 1884 by Robinson of New York, 
where it appears to be fairly common, while in England it is 
rare, but in the west of Scotland Adam saw nine cases. 

It is limited to the face, chiefly above the level of the mouth, 
especially on the nose and adjacent part of the cheeks, and in 
the middle of the forehead. The lesions are tense, clear, shiny, 
deep-seated, whitish vesicles, but they may be solid-looking, 
and the larger ones project considerably. Sometimes there is 
slight itching, but no sign of inflammation in or about them, 
the intervening skin being quite normal. They have been com- 
pared to boiled sago grains when small, while the larger ones 
are dark bluish at the periphery, Robinson says, but in a case of 
mine some of them were dark in the center like a comedo; the 
rest were translucent, or of the color of the normal skin. 
Rosenthal compared them to milium, but this seems correct 

* Galloway, loc. tit., vol. xiv. (1902), p. 168. 

\ Literature.— Jour, of Cut. and Gen.-Ur. Dis., vol. ii. (1884), p. 362, 
and August, 1893, colored plate. " Dysidrosis,'" G. T. Jackson, loc. tit., 
vol. iv. (18S6), colored plate. "Dysidrosis," Rosenthal, Deutsch vied. 
Wochensch., No. 20,1887. " Hidrocystoma." James Adam, B rit. Jour. 
Derm., vol. vii. (1895), p. 169, with histology plates. "Miliaria Pro- 
funda," Pollitzer on the Miliaria group, X. V. Med. Jour., January 6, 
1894, histological. " Hidrocystoma," G. Thibierge, Annates de Derm, et 
de Syfth., November, 1895; Abs. Brit. Jour. Derm., vol. viii. (1896), p. 146. 



no8 DISEASES OF THE SKIN. 

only for the declining stage. They are discrete for the most 
part, but above the naso-labial folds are sometimes so crowded 
as to touch, but do not coalesce, and they have no special 
arrangement. The majority are from a pin's head to a hemp 
seed in size, but some are as large as a pea. When pricked a 
clear acid fluid escapes, and the vesicle collapses, but they do 
not rupture spontaneously, the contents being slowly absorbed. 
The vesicles develop most in the summer, and decline to nearly 
vanishing point in the winter, but seldom go away entirely; in 
Morton's and Hallopeau's cases the vesicles became more 
prominent at the monthly periods. The disease may recur year 
after year for many years. Middle-aged women who are ex- 
posed to heat in their occupations over the fire or washtub are 
the most frequent victims, but a patient of mine was a man of 
forty in good circumstances, and Robinson had a case in a man 
of twenty-eight. Unilateral cases with unilateral sweating have 
been several times observed, or the disease may be limited to 
the nose, with or without including the interorbital space. 

Diagnosis. — The eruption presents few difficulties in diag- 
nosis. Its limitation to the face, the persistent vesicles being 
deeply seated in the cutis, with acid contents and absence of 
all signs of inflammation, are characteristic, and distinguish it 
from the superficial, widespread, and transitory sudamina; from 
pompholyx, which is a disease of the extremities; from the obvi- 
ously inflammatory eczema; and from all solid miliary lesions 
of the face, such as adenoma sebaceum, acanthoma, adenoma 
cysticum, etc. 

Anatomy. — Robinson found that the vesicles arose from dilatation of 
the excretory duct of the sweat glands in the deep part of the corium, 
but argues that it is not a mere retention cyst, as the wall is always 
lined with cells derived from proliferation of the duct epithelium and the 
lesion in some respects is suggestive of a new growth. Pollitzer's and 
Adam's observations confirm Robinson's anatomical facts, but Pollitzer 
regards them as retention cysts, while Adam considers that the coil is 
involved rather than the duct; the secreting part being hypertrophied, 
and the duct being not large enough to discharge the increased secretion, 
dilatation behind it occurs. 

Treatment. — The best treatment is to puncture the vesicles. 
Rosenthal found a two per cent, solution of naphthol in spirit 
beneficial. The result is palliative rather than curative. 



TUMORS OF THE SWEAT GLANDS. 1109 



TUMORS OF THE SWEAT GLANDS.* 

The tumors arising from, or in connection with, the sweat 
glands are of pathological rather than clinical interest, as it is 
impossible to diagnose them in the present state of our knowl- 
edge without excision and histological examination. Only suf- 
ficient references can be given here to enable the student to 
follow up the subject. Some cases of rodent ulcer have appar- 
ently been traced to a sweat gland origin. In my case of 
Paget's disease of the scrotum there were certainly sweat 
gland changes of a cancerous character, but whether primary 
or secondary it was not possible to determine, and cancerous 
developments from these glands have been found by other au- 
thors, such as Fordyce, Darier, etc. Petersen, Elliot, Villard, 
and Paviot have shown that some cases which look like naevus 
verrucosus unius lateralis are really of sweat gland origin; and 
nsevus corne of the sweat gland orifices, such as have been 
described by Hallopeau, Besnier, and Respighi, are probably 
of the same character. Betham Robinson at the Pathological 
Society, 1898, showed a sudoriparous cyst from the axilla one 
and a half inches across. 

* Literature. — Unna's " Histopathology,"pp. 699, 710, 806-814, abstracts 
and references to many cases. Fordyce, " Adeno-Carcinoma of the Coil 
Glands," Amer. Jour. Cut. and Gen.-Ur. Dzs., vol. xiii. (1895), p. 41, 
with many references to date. " Neviform Sudoriparous Tumors," 
Villard and Paviot, Second French Congress of Internat. Medicine at 
Bordeaux in August, 1895. Sem. med., 1895, No. 42. Audry, " Fibrome 
periacineux des glandes sudoripares," Jour. Mai. Cut., vol. vii. (1895), 
p. 650. Morisani, "Adenoma sudoriparum," Naples, 1887, gives many 
references to old cases. Audry excised a cyst from the back of the ring 
finger of a man of sixty, and found it full of gelatinous contents, and 
thought from the histology that it was in all probability of sweat duct 
origin, Annates de Derm., etc., vol. i. (1900), p. 123. 



1 1 io DISEASES OF THE SKIN. 

B.— DISEASES OF THE SEBACEOUS GLANDS. 

SEBORRHEA. 

Deriv. — Sebum, or scvwn, suet, and peao, to flow. 

Synonyms. — Sebaceous flux; Stearrhea; Steatorrhea; Sebor- 
rhagia; Fluxus sebaceus; Acne sebacea; Pityriasis; Ich- 
thyosis sebacea; Tinea amiantacea; Tinea asbestina; Ec- 
zema seborrhoicum (Unna); Fr., Acne sebacee; Gcr., 
Schmeerfluss; Gneis. 

Definition. — A disorder of the fat glands, producing increase 
and alteration of the secretion, which forms an oily, waxy, or 
scaly accumulation on the surface. 

Symptoms. — Seborrhea may be general or local in its distribu- 
tion, and in one or other of its forms is a common condition, 
especially in the regions where oil is normally most abundant, 
viz., the scalp, the upper and central parts of the face, the front 
of the sternum, the interscapular region, the pubes, and inguinal 
regions. 

Since there is so much that is debatable in the nature and 
origin of the morbid forms included under this title, the clinical 
features will be set forth: first, of those varieties in which there 
are no external signs of inflammation, and, secondly, of those 
in which the inflammatory phenomena are more or less manifest. 

In the first series is included an oily, a waxy, and a scaly 
form, although the last two are mixed conditions. 



i t>' 



Seborrhea Oleosa [Synonyms. — Fluxus sebaceus; Fr., Acne 
sebacee huileuse (Besnier) ; Hyperidrose huileuse (Brocq) ; Acne 
sebacee fluente (older writers)]. In this affection, which is a 
common one at puberty and onwards, and varies greatly in 
degree, the skin feels and looks greasy and shining, and a thin 
oily secretion is spread over the surface. Its most common 
position is on the face, especially the forehead, cheeks, and nose, 
and then the complexion is generally thick and muddy, and, 
owing to dust, etc., adhering so readily, the skin always looks 
dirty and acne vulgaris is a usual concomitant. On the nose it 
is often associated with venous congestion, rendering it a deep 



SEBORRHEA. mi 

red, but cool to the touch, while the openings of the follicles are 
unusually prominent, and filled with soft, fatty, easily expressed 
plugs, or covered with a dirty, fine, slightly adherent scale. 

On the scalp, which is almost always also affected, it does 
not attract much attention, except in bald persons, to whose 
heads it imparts an extra polish. 

It may also be seen on the trunk, especially the back, gen- 
erally with acne vulgaris and comedones. 

According to Unna the secretion is derived from the coil 
of the sweat glands, and not from the sebaceous glands, and 
this is the only affection he considers entitled to the name of 
seborrhea. 

Wallace Beatty * urges many cogent facts in favor of the old 
view as to the origin of the secretion, but finds traces of an 
inflammatory process. Robinson of New York also argues in 
favor of the old view. At the same time no one disputes that 
there is a certain amount of fat in sweat, which in the new-born 
is much in evidence, while the sebaceous glands are small and 
inactive. Leslie Roberts proposes the term oleorrhea for ex- 
cessive oily secretion from the sweat coils. 

Seborrhea Sicca is generally made to include the waxy and 
the scaly forms, as they may be associated or shade off into 
each other. They are both very common and important, as 
they are the chief causes of premature baldness. 

The waxy form (S. cerea) varies much, according to its de- 
gree and position, and the age at which it occurs. In the new- 
born it is the vernix caseosa, and though varying in quantity, 
is physiological rather than pathological; whether of coil or 
sebaceous gland origin is still disputed. 

In the first year of life sebum is normally abundant, and, 
mainly from insufficient washing, often accumulates on the 
scalp, chiefly at the vertex, where it forms a dirty-yellow mass, 
sometimes of considerable thickness and cheesy consistence; 
when raised up the skin beneath is pale and healthy, unless it is 

* Brit. Jour. Derm., vol. vi. (1894), p. 161, a good review of the pros 
and cons of Unna's views, with original observations. Unna's " Histo- 
pathology of the Skin " should also be referred to. See also Seborrhea 
discussion opened by Colcott Fox, Brit. Med. Jour., vol. ii. (1901), p. 855; 
also at Manchester meeting of B. M. A., 1902. 



III2 



DISEASES OF THE SKIN. 



irritated by decomposition of the fat, when it may set up an 
eczema — a not infrequent event; otherwise it can scarcely be 
said to transgress the physiological limit. The origin of this 




Fig. 66. — A Normal Sebaceous Gland, in connection with a lanugo hair 

(Neumann). 

a, connective tissue capsule; b, fatty secretion; c, k, fat-secreting cells; 
d, root of a lanugo hair; e, hair sac;/", hair shaft; g, acini of seba- 
ceous gland in connection with an ordinary hair may be seen at the 
beginning of the section on diseases of the hair. 



fatty deposit is also said by Unna and others to be not of really 
sebaceous origin, but there are many who hold that it is. 

The same may be said of the fatty secretion called smegma, 
which may accumulate on the glans penis under a long prepuce, 
and in women on the clitoris or labia where proper ablutions 
are not practiced. Here also its decomposition is liable to set 
up inflammation and produce balanitis or vulvitis. 

At puberty and onwards it is seen most commonly at its 



SEBORRHEA. 



1113 



highest development upon the scalp, where it forms dirty-look- 
ing yellowish or greenish-brown, or even black plates or crusts 
of fat and epithelium. Its most common appearance is that of 
soft yellow wax. When in small quantity, or in the early stage, 
it can be seen that these fatty scales are seated at the hair folli- 
cles of the vertex, temples, and adjacent parts — and on removal 
of the secretion a funnel-shaped depression may often be seen 
round the hair.* The disease is then more serious than it ap- 
pears, as it leads to atrophy of the hair, and if not persever- 
ingly treated, to premature and permanent baldness, of which 
it is the most common cause. This it may do when it is insuf- 
ficient of itself to attract the patient's attention, for in cleanly 
people it is easily overlooked, and the loss of hair is the condi- 
tion for which advice is sought. In more severe cases it may 
extend all over the scalp, and form a fringe from one-half to an 
inch wide all round, with well-defined margin and fatty scales; 
more or less obvious inflammation is then generally present. 
It may also occur on the hairy parts of the face, where it also 
leads to loss of hair. In girls it may be seen on the eyebrows, 
with very slight redness and scaliness, but with gradual shed- 
ding of the hair. It may be associated with some defect in the 
general health, and is very difficult to cure completely. 

In the milder cases the scaly element is more pronounced 
and the fatty characters not obvious until the surface of the 
scalp is gently scraped. Again, sometimes the secretion is more 
oily than waxy, and the patient complains that the hair is always 
moist as well as being abnormally shed. 

The scaly form (S. furfuracea seu pityriasiformis) used to 
be, and is still, regarded by some authors as a separate affec- 
tion, and has been also called pityriasis simplex, acne sebacee 
seche, eczema seborrhoicum squamosum (Unna), dandriff, etc. 
Many persons are troubled by their heads being constantly cov- 
ered with fine, white, shining scales, which brush or shake out 
on to their clothes, to their great annoyance. Examination of 
the scalp shows that it is more or less thickly covered with these 

*In a young man at U. C. H. there was a general and extensive thin- 
ning of the hair with marked infundibulation round the hair and very 
little seborrhea, but in parts there were fatty plugs which could be ex- 
pressed like a comedo. In many hairs the medulla was interrupted, but 
in most it was quite absent. 



1 1 1 4 DISEASES OF THE SKIN, 

scales in the same positions as the waxy form, and the lower 
layers are slightly adherent to the scalp. This condition is fa- 
miliarly known as scurf, or dandriff, and generally leads to 
atrophy of the hair, which becomes dry, brittle, lusterless, and 
sometimes gray, and falls out or is easily combed out every day 
(alopecia pityrodes of Pincus), but in some cases the hair is 
abundant, though often gray or white. The scalp beneath the 
scales is generally quite white, but there may be considerable 
hyperemia, burning, or itching. It may, however, last for 
years without any external sign of inflammation. A similar con- 
dition occurs on the whiskers and beard, but less frequently. 

On the face, generally from the irritation of soap, patches 
w T ith small scales of white tint with or without slight subjacent 
hyperemia, are frequent in children; the patches are rather well 
defined, extend peripherally, but in irregular shapes, especially 
when several are confluent. Whitfield found a micrococcus, 
which did not liquefy gelatin, invariably present. In strumous 
children it may be pretty general on the trunk and limbs in 
small shining scales, and it is very often present along with 
lichen scrofulosus. 

In the aged, with degenerated skins, dirty-looking branny or 
powdery scales may cover the whole body to a greater or less 
degree, and a similar condition occurs sometimes in diabetes 
and other chronic wasting diseases (S. tabescentium). The 
most modern view is not to regard these conditions as really 
seborrheic. 

Under the name of Alopecia Pityrodes Universalis, P. Mi- 

chelson describes * a rapid and general denudation of hair oc- 
curring in debilitated states, which differs from alopecia areata 
universalis neurotica in being preceded by abundant desquama- 
tion of fatty scales; in the apparently bald places, being cov- 
ered with fine colorless lanugo hairs, or with hair rudiments; 
and instead of the skin being thin and lax, as in alopecia areata, 
being rather firmer and stiffer than normal. Moreover, the 
prognosis is good. Besides general tonic measures Michelson 
recommends local ablution with spirituous soaps or weak solu- 
tions of corrosive sublimate or chloral hydrate. It appears to 
me to correspond with S. sicca, except in the rapidity and extent 
* Monatsh.f. prak. Derm., 1882, No. 4, and Ziemssen, p. 418. 



SEBORRHEA. 



L 5 



of the denudation of the hair, and in cases which I have seen 
there has always been some degree of visible inflammation 
present. 

5\ congestiva is the name given by Hebra to what is now 
known to be the early stage of lupus erythematosus. 

5\ corporis of Duhring will be presently described. 

Etiology. — Excluding the infantile form, which hardly 
amounts to disease, it is particularly common at puberty, when 
all the glands become especially active. It is more common in 
women than in men after fifty, but, taking all ages, there is no 
material difference; fair people are more prone to S. sicca, and 
dark to S. oleosa. It appears to run in families sometimes; or, 
at all events, it is not uncommon to find that all the men of 
a family lose their hair prematurely, and seborrhea is generally 
present in such cases. 

It is a much more obstinate disease in the old than in the 
young, and also more important, on account of the baldness 
it entails. In many cases there is some defect of health, gen- 
erally of a debilitating character. In girls chlorosis is one 
such cause, and even young men suffering from seborrhea are 
sometimes pallid and out of health, and may be the subjects of 
struma, comedones, and acne vulgaris. After the climacteric 
period women are especially liable to it, frequently without any 
uterine disorder being present. It is said to be more common 
in those who sweat readily, but I have known many instances 
in which luxuriant hair and heavy sweating have been associated. 
Syphilis also is a strongly predisposing influence in both sexes, 
and other chronic exhausting diseases, such as phthisis and 
chronic cancer, are responsible for a certain number. A more 
transitory condition is often seen after severe illnesses, such as 
the exanthemata and other fevers, with considerable loss of 
hair. Smallpox especially is apt to give rise to scutiform, 
closely adherent crusts on the face, either broken up or in a 
continuous patch. Finally, in a large number of cases no cause 
whatever can be assigned for it, the patients being in robust 
health, and one can only assume a tissue proclivity which offers 
a favorable soil for the seborrheic micro-organism. 

Pathology. — Although Henle and Meissner long ago had 
stated that the sweat glands secreted fat as well as water, Hebra's 
views were generally accepted: that all the conditions just de- 



ii 1 6 DISEASES OF THE SKIN. 

scribed were the outcome of seborrhea; that this was primarily 
an exaltation of the natural function of the sebaceous glands; 
that the difference in consistence depended mainly on the 
idiosyncrasy of the individual, on the admixture of scales from 
the more or less free exfoliation of the cells of the hair follicles 
and epidermis, and from imperfect fatty metamorphosis of the 
lining cells of the sebaceous glands. This comfortable and 
plausible explanation was rudely shaken by Unna in 1881 and 
1894, who claimed the most important role as lubricators of the 
skin for the coil glands, the secretion being chiefly oleic acid, 
while that of the sebaceous glands was chiefly stearic acid. 
Much can and has been said both for and against this view of 
Unna's, and while no one disputes that oil is formed in the 
sweat coils, its amount * and relative importance are still matters 
of active controversy. Unna also advocated the view, which 
is pretty generally accepted, that, while seborrhea oleosa and 
the vernix caseosa are the only conditions of mere excessive 
secretion, the firmer kinds are really of inflammatory origin, 
" a dry catarrh of the skin, in fact," mixed with fat, while the 
clinical signs of inflammation may be wanting. The sebaceous 
glands are very little altered at first, but ultimately there is an 
obstruction to the issue of fat, and a consequent arrest of secre- 
tion, the lobules being full of fatty cells, but not of undegen- 
erated epithelium. Unna confirmed the statement of Pincus, 
Piffard, and Van Harlingen, that the scales of seborrhea sicca 
are produced, not from the sebaceous glands, but from the 
horny epidermis; and Sabouraud says that they have a peculiar 
and specific cause, a gray-colored coccus and the " bottle ba- 
cillus." This scaliness is not necessarily, though generally, 
mixed with seborrhea. For Sabouraud there are two forms of 
seborrhea, viz., seborrhea oleosa and the comedo, which is a 
cystic transformation of a primitive seborrheic plug; but while 
Unna regards seborrhea oleosa as of sweat coil origin, Sa- 
bouraud says that it is a hypersecretion of the sebaceous glands 
due to the seborrheic micro-bacillus. 

While not disputing that the microscope reveals signs of a 

very slight degree of inflammation, clinically there is usually no 

evidence of it, and after removing the fatty crusts the skin looks 

quite white and normal. Clinically, therefore, it is convenient 

* Kreidl says that there is one per cent, of fatty acids. 



SEBORRHEA. 1117 

to use the old nomenclature for these affections with fatty 
deposition on the skin without external signs of inflammation, 
and to describe the definitely inflammatory forms separately. 

While for Unna the " morococcus " he has found is the cause 
of both the apparently non-inflammatory and the obviously 
inflammatory conditions, Sabouraud regards the seborrheic 
micro-bacillus as the cause of the true seborrhea, while various 
forms of inflammation are excited by the addition of other 
microbes, e. g., staphylococcus aureus, or a gray-cultured coccus; 
hence on the seborrheic basis arise acne necrotica varioliformis, 
acneic furunculosis, chronic furunculosis of the neck, sycosis 
and acne keloid. While the chief points of controversy are set 
forth, it must be left to future workers to show which views 
are correct. 

Diagnosis. — In the absence of secondary inflammation the 
diagnosis is not difficult. 

S. sicca is most like eczema, but the crusts are fatty, and do 
not consist of inflammatory exudation, and, when raised, the 
skin beneath is white and dry, while in eczema it is red and 
moist. In scaly seborrhea hyperemia is either absent or slight, 
the itching is comparatively little and often absent, the pityriasis 
is diffused over the scalp, and is always dry throughout its 
whole course; in eczema the redness is always well marked, 
there are generally discharge, marked infiltration, and itching, 
and it is often only partial in its distribution. 

This form is also like psoriasis, but psoriasis is always in well- 
defined patches, the scales are adherent, very abundant, and 
larger than those of seborrhea, and, when removed, the surface 
below is very red and the disease is seldom limited to the scalp. 

Seborrhea of the face, with hyperemia, is very like a slight 
eczema; here, again, there is never any discharge, the scales are 
evidently chiefly fatty, and there are often other signs of sebace- 
ous disorder. 

The diagnosis between seborrhea of the face and lupus erythe- 
matosus is given under the latter disease. 

Prognosis. — In infants and young people the prognosis is 
good, but when of long standing it is always obstinate, and may 
be incurable; but it can always be temporarily benefited and 
be kept under by applications once or twice a week. On the 
scalp, even in the comparatively young, if of long standing, it is 



iii8 DISEASES OF THE SKIN. 

often fatal to the hair of the affected region, restoration rarely 
occurring, and then being only partial; but in recent cases there 
is fair hope of success. 

Treatment. — The indications for internal treatment are to be 
sought in the etiology; the defects in health should be carefully 
looked for, corrected, and every effort should be made to place 
the patient under the best conditions as regards himself and 
surroundings that circumstances permit. Iron and cod-liver oil 
are the two remedies of most frequent utility, but the alimentary 
canal often requires preliminary attention. Arsenic is some- 
times useful in the scaly cases. Duhring speaks in favor of 
sulphur, especially in the form of calcium sulphid, one-fifth of a 
grain three times a day; but treatment on general principles is 
more reliable than specifics, which only find a place when the 
special indications are absent. 

It must, however, be acknowledged that internal medication 
only plays a subordinate part in the removal of the disorder, 
and its microbian pathology explains what practical experience 
has proved, viz., that: 

Local treatment is of the greatest importance. In infants all 
that is required is that the fat crusts should be softened with 
strips of flannel dipped in olive oil and laid on the scalp, or 
the oil may be well rubbed in, and the head washed thoroughly 
with soap and water; a little oleate or oxid of zinc ointment may 
be afterwards applied for a few days. 

In older people, or where the crusts are very adherent on the 
scalp, the soap and spirit liniment will facilitate removal of the 
crusts and scales, and the addition of oil of cade, or the less 
disagreeable thymol, gr. xv in one ounce of the liniment, in- 
creases its efficacy. This would be used about once a fortnight 
as a preparation for other remedies, which for the scalp will 
be set forth under Seborrheic Alopecia. 

Seborrhea nasi is often very troublesome, and produces 
much distress of mind to the young people who are most sub- 
ject to it. If it is simply oily, a thorough washing with soap and 
water and then rubbing on a powder of sulphur prsecipitatum 5i, 
emol keleet or cimolite Six, is often efficacious. 

If there are fatty plugs, whether soft or hard, these should be 
expressed with the blunt side of a curette or with the thumb- 



SEBORRHEIDES. 1119 

nails, and the stronger antiseptic and spirit soap liniment should 
be rubbed on with flannel dipped in hot water, then rinsed off, 
and the same powder applied, or a calamin lotion with hydrarg. 
perchlor. gr. 1-4 to the 5J or sulph. prsecip. gr. iij to the §j 
painted on and allowed to dry. 

Judgment must be exercised so as not to use the spirit soap 
too frequently and thus inflame the skin. In both these forms 
disorders of the alimentary canal are frequently present and 
must be attended to. Where the face is generally affected sim- 
ilar treatment may be employed, but probably less vigorously. 
Where there is only slight hyperemia, precipitated sulphur, 
more or less diluted with starch and oxid of zinc, may be 
scented with attar of rose and used with a powder puff; for the 
body ten to thirty grains of sulphur to an ounce of lanolin is 
all that is required, sometimes 5j to the gj may be employed. 
Whatever the treatment adopted it should be energetically and 
perseveringly pursued. 

SEBORRHEIDES. 

This is a convenient term used by French writers for the 
various inflammatory eruptions which arise in connection with 
seborrhea, and is the analogue of syphilids, tuberculids, etc. 
It must not, however, be considered as proved that because 
seborrhea is an antecedent and concomitant of these forms of 
dermatitis that the seborrheic bacillus is the direct cause of 
them. It is highly probable that seborrhea only offers a spe- 
cially favorable soil for the cultivation of various other organ- 
isms. As an example of how this may come about, vide Sa- 
bouraud's views as set forth in Alopecia Seborrhoica. 

Seborrheic Dermatitis [Synonym. — Seborrhoic eczema 
(Unna)] comprises various forms of the second series in which 
the clinical signs of inflammation are present, and resemble 
more or less closely various forms of ordinary dermatitis. 

Duhring was the first to point out that a certain form of 
inflammation of the skin, which had long been known under 
the name of lichen circinatus and other synonyms, was inti- 
mately associated with seborrhea capitis, and was, he consid- 
ered, the same disease modified by position, and he called it 
therefore seborrhea corporis. Unna, from a careful study of 



ii2o DISEASES OF THE SKIN. 

S. capitis by the microscope and of the clinical relations of the 
disease, came to the conclusion that not only was S. capitis an 
inflammation of the skin, seated chiefly in the coil glands rather 
than the sebaceous glands, but that the various forms of derma- 
titis which are met with in regions where the coil glands are 
abundant, such as the axillae, groins, interscapular regions, and 
even the palms and soles, are not only of the same nature as 
S. capitis, but are in most, if not in all, instances due to the 
direct transference of the same pathogenic organism from the 
head to the region affected, and that in its new abode the irri- 
tative presence of the parasite excites dermatitis of various 
forms, which he would embrace in one large group, viz., sebor- 
rheic eczema. 

There can be no doubt that much credit is due to Unna for 
an important generalization; but the majority of dermatolo- 
gists, except his most faithful disciples, consider that he is giv- 
ing to his seborrheic eczema too extended a meaning, which der- 
matology will be a loser rather than a gainer by adopting un- 
reservedly. 

Without disputing that there may be a microscopical amount 
of inflammation in all S. capitis, everyone will admit that only 
in a small number can it be recognized clinically, and I have 
therefore adhered to the old well-known term. 

Under certain circumstances active inflammation may super- 
vene, and on the body more or less inflammation is the rule, 
when the presumptive parasite is successfully planted out. It 
is proposed to discuss in the present section the varieties of 
dermatitis thus excited, all of which, in my opinion, it is not 
wise to include under the one term seborrheic eczema. As a 
matter of fact the dermatitis may imitate an eczema, a psoriasis, 
or a lichen, and a clearer conception may be gained of a multi- 
form process by adopting terms that point out the clinical re- 
semblances. It must be borne in mind that there is the possi- 
bility that these various inflammations may not be all directly 
seborrheic, but that the presence of seborrhea offers a suitable 
soil for the growth of other microbes. 

Seborrhea Eczemaformis (the Eczemaform Seborrheide).* 

Seborrhea may go on for years upon the head without show- 

* Author's Atlas, Plate X., Figs. 2 and 4, circinate eruption of the face 
and nape; Plate XI., extensive papulo-squamous eruption of the back; 



SEBORRHEIDES. 1121 

ing any external sign of inflammation, and without even at- 
tracting the patient's notice, except by the gradual thinning of 
the hair which it induces; or, if the branny form, by the scaly 
dust that is shed upon the clothing. Then, under some de- 
pressing influence, either mental, such as worry or anxiety, or 
bodily illness, active inflammation supervenes; the scalp be- 
comes hot and red with abundant flaky and fatty scales, and the 
affection is perhaps no longer confined to the hairy scalp, but 
extends beyond for a short distance, with bright redness of the 
skin, more or less scaliness, and a well-defined margin. Dis- 
charge is often absent, but may be easily excited by scratching 
or the slightest irritation, whether from injudicious applica- 
tions or other cause; but, from the large admixture of fat, the 
crusts are softer and less adherent than in ordinary eczema of 
the head. The lower part of the face is seldom involved in such 
cases; but if there are any patches they are always well defined 
and do not discharge. 

Unna also includes under seborrheic eczema the dry, scaly, 
slightly reddened patches, with well-defined borders, often seen 
on the back and sides of the neck, sometimes extending into 
the scalp. They are generally roundish solid patches, but 
sometimes have a gyrate outline. 

They are the lichen circwnscriptus or simplex of Yidal. 

Round, well-defined, dry scaly patches are occasionally seen 
on the limbs and trunk, which are probably, but not demonstra- 
bly, of seborrheic origin. 

A milder form of inflammation is, however, not infrequent as 
an independent affection on the nose, cheeks, or forehead, the 
affected area being only pale red, with defined margin and dry, 
scaly surface. 

The treatment for this condition is that for other active in- 
flammations of the skin, plus bactericides, of which iodoform is 
one of the best — c. g., iodoform gr. 10, ung. zinci oleat. §j, or 
rjoric acid ointment §j, with gr. 4 of europhen, either ointment 
to be applied. constantly. Sulphur from gr. 5 to gr. 20 is also 
valuable. Where the inflammation is not so active, resorcin 
gr. 10, and liq. plumbi subacet. m\xx, adip. benz. gj. is a good 

Plate LXXX., acute inflammation of the head and face, supervening 
after great worry on a long-standing seborrhea capitis. Fig. 2 of this 
plate illustrates eczema palmse. 

72 



1 1 22 DISEASES OF THE SKIN. 

formula; and in slight degrees of inflammation precipitated 
sulph. gr. 10 to ung. simplicis 5J, or weak ammoniated mercury 
ointment, with or without the yellow oxid, are excellent appli- 
cations. These stronger ointments should be gently rubbed 
into the scalp two or three times a day. 

Internally, any derangements of the alimentary canal must 
be rectified, and then such tonics as may be suitable should be 
given, with a supporting diet, but with very little alcohol. 

Chronic patchy forms are most benefited by mercurial or 
sulphur applications; but resorcin, salicylic acid, or naphthol 
are good alternative drugs. Vasogen iodin ten per cent. 5ij, 
paraffin liquidi §ij is a good formula. 

On the body papular and scaly forms of inflammation are 
most frequently met with. Eczema palmare, which Unna con- 
siders seborrheic, is described with ordinary eczema. 

Seborrhea Psoriasiformis (the Psoriasiform Seborrheide).* 

— This is one of the least common forms. It is the form of 
disease of which cases were described by Brooke f and by Wick- 
ham.:!: It consists of well-defined, bright red patches, with 
scanty, scaly, and fatty crusts, contrasting with the bright, 
silvery epithelial crusts which almost always cover a typical 
psoriasis patch which has not been interfered with, but it is 
very like a psoriasis in which the scales have been partially 
removed by treatment or free sweating. The individual patches 
are not large, roundish, and may clear in the center; but they 
may coalesce with others, and then cover a considerable area. 
The eruption is chiefly met with in the axillae and on the trunk, 
but may appear slightly on the face and upper part of the 
limbs, but does not affect the usual psoriasis positions on their 
lower segments. 

A few patches may also be seen on the scalp, and then they 
are more crusted; but more frequently there is only ordinary 
S. capitis, without signs of inflammation. 

The diagnosis might be made by the distribution, the scales 

♦Author's Atlas, Plate LXXXI., Fig. 1. 

f Brooke, "The Relation of the Seborrheic Processes to some other 
Affections of the Skin," Brit. Jour. Derm., vol. i. (1889), p. 247, with 
colored plate. 

JWickham, Letter from Paris, ibid., vol. iii. (1891), p. 256. 



SEBORRHEIDES. 1123 

being more fatty and less abundant, by the surface being a 
deeper red than most cases of psoriasis and by the presence of 
S. capitis. 

The treatment should be to remove the scales with soft soap 
and then rub in a mild parasiticide. Thymol, resorcin, or sulph. 
praecip. gr. 10 to gr. 20 to gj of lard, vaselin, or lanolin. 

The S. capitis should also be treated, and any defect in the 
general health attended to. 

Seborrhea Papulosa seu Lichenoides (the Papular Sebor- 
rheide).* [Synonyms. — Lichen circinatus; L. circumscriptus 
(Willan and Bateman); L. annulatus serpiginosus (Wilson); 
Seborrhea corporis (Duhring); L. gyratus (Biett and Caze- 
nave).] 

Definition. — A serpiginous, papular, ringed eruption, limited to 
the trunk and associated with seborrhea. 

Symptoms. — Slight degrees of this disease, which was first 
described by Willan and Bateman, are fairly common, though 
it is often only discovered accidentally, as it gives rise to no 
inconvenience beyond slight itching. It is for the most part 
limited to the middle and front of the chest and the inter- 
scapular region; or in more extensive cases occupies a triangular 
area with the base at the shoulders and the apex at the lumbar 
region. It may occasionally spread over the greater part of 
the trunk; but the limbs, except where they join the trunk, 
and the face are never affected. It begins as a group of 
rounded, small pin's-head-sized, bright red papules, occasion- 
ally with a scale on their apex, which soon coalesce into a disc 
about two lines in diameter; and as this enlarges peripherally 
the center clears, forming a ring, the papular structure of which 
is more or less evident, while the central area is of a fawn color. 
When several rings coalesce the margin is broken, and a fawn- 
colored, slightly scaly area is produced, resembling tinea versic- 
olor, when of considerable size, but bounded incompletely by 
a red, gyrate, slightly raised papular margin. Isolated lesions 
of circles, or segments of circles, are situated in the neighbor- 
hood of the main patch, and here and there are scattered 
papules ready to start a fresh one. Slight scaliness and marked 
greasiness (seborrhea), are almost invariably present on the skin, 
* Author's Atlas, Plate LXXXII. 



H24 DISEASES OF THE SKIN. 

and seborrhea of the scalp is associated in a large proportion 
of cases. 

Etiology. — The disease is most frequent in those who sweat 
freely and wash sparingly, and is so common in those who wear 
thick woolen underclothing that at the Blackfriars Skin Hos- 
pital it is familiarly known as " flannel rash." * It is more 
common in men than women. 

Diagnosis. — The characteristic features are the fawn-colored 
areas, with red, papular, ringed, or gyrate borders, situated in 
the middle of the chest and back, and never affecting the limbs. 
The position and yellow color of the internal area render it 
easily mistakable for tinea versicolor, but the characteristic 
fungus of the latter disease is absent, and the tinea lacks the red 
papular border of the L. circinatus. The diagnosis from 
pityriasis circinata is given with that disease. 

Treatment. — This is simple and effectual, and need only be 
local. Any mild parasiticide, such as glycerin of borax, thymol 
gr. 20 to adipis §j, rubbed in night and morning, will speedily 
remove the eruption, even when it has been present for years. 
A few weeks' watchfulness against recurrence, owing to insuffi- 
cient treatment, and more frequent ablutions and change of 
underclothing are necessary to prevent recurrence. 

SEBACEOUS CYSTS. 

Synonyms. — Wen; Atheroma; Steatoma. 

Definition. — A cystic tumor with sebaceous contents. 

Symptoms. — Sebaceous cysts vary from a millet seed to an 
orange in size, are roundish in shape, and either flattened or 
hemispherical. They may be single or multiple, of doughy con- 
sistency usually, but if inflamed, may become quite pultaceous, 
or if old, rather hard. They are freely movable under the skin, 
not tender or painful, and grow very slowly as a rule. The 
skin over them is normal, or white from distention unless they 
are inflamed, when it becomes red, and the cyst may break 

*In some lectures on " Lichen," in the Lancet, in 1881, I described and 
figured a fungus which I then thought was the cause of the disease, but 
further observation has convinced me that its presence was accidental. 
Micrococci are abundant enough, but where are they not? 



SEBACEOUS CYSTS. 1125 

down and ulcerate and perhaps fungate, resembling a rodent 
ulcer (see " Follicular Disease of the Scalp "). Their common- 
est positions are the scalp, face, neck, and back, but they may 
grow anywhere where there are sebaceous glands, and in rare 
instances, even where there are none normally, such as on the 
palms, fingers, soles, in the floor of the mouth, under the 
tongue, and even in the anterior chamber of the eye after 
wounds. These are sometimes called dermoid cysts to distin- 
guish them, but are not true dermoids, which are of congenital 
origin. When the duct is patent, they are usually flat, not very 
large, and are commonly situated in the thick skin of the back 
and neck; but I have excised one as large as a walnut from the 
chest. It is from this kind that so-called horns may develop 
(see " Cornua "). When the duct is closed, they are usually 
globose, and grow most frequently on the scalp, but are hair- 
less. They are most common in middle-aged women. 

Multiple sebaceous cysts in every region of the body are 
considered separately. They are probably the same as the 
sudoriparous fat cysts of Dubreuilh (see p. 1058). 

Another form is the tumors in connection with the Mei- 
bomian glands, from a pin's head to a nut in size, though not 
often larger than a pea. To these the term Chalazion is given; 
they often recur, and are sometimes numerous. Although these 
little tumors are generally placed among sebaceous cysts, Vir- 
chow years ago, and quite recently Weyman, have shown that 
they are really neoplasms of the granuloma order; and accord- 
ing to Weyman, a fungus can be demonstrated, which he calls 
the " fungus chalazicus," and considers it pathogenetic. 

Pathology. — Sebaceous tumors are said to be caused by accu- 
mulations of epidermis and sebaceous masses in the follicles, 
with hypertrophy of their walls. Paget, however, regards them 
as new growths. The gland is obliterated quite early, and the 
secretion must therefore come from the cyst wall. The con- 
tents may be meliceric, i. e., fluid and honeylike, consisting of 
free fatty granules and epidermic cells, or steatomatosis of more 
firm consistence, with more epidermic cells and less free fat. 
Cholesterin is generally present, and sometimes coiled-up hairs. 
The cyst wall is described by Cornil and Ranvier as made up 
of connective tissue with flat cells and parallel lamellae of 
ground substance. It is lined with epithelium, comparable to 



1 126 DISEASES OF THE SKIN. 

that of the tunica interna of the arteries, and in it also fatty, 
calcareous, and atheromatous changes are common. To ac- 
count for sebaceous cysts in the eye, palm, etc., after wounds, it 
has been suggested that at the time of the wound some part of 
a sebaceous gland had been transplanted on to the wounded 
part, but there are no known facts to support such a theory 
and probably the inclusion of epidermic cells of any kind is 
sufficient, just as dermoids are considered to be due to the 
inclusion of embryonic epidermis. Their possible origin from 
embryonic remnants in the cutis must also be remembered. 
Torok's observations go to show that nearly all sebaceous cysts 
are really dermoids, that there are papillae with an epithelial 
covering in the cyst wall, and that it was the exception to find 
fat in the cysts, and that therefore it could not be sebum. True 
retention cysts are macro- and microscopically distinguishable, 
and allied in structure to the double comedo.* 

Diagnosis. — With the duct patent the nature of the tumor is 
obvious, and some of the contents can be squeezed out as fur- 
ther proof. When the duct is closed it may resemble a fatty 
tumor; but the position and absence of lobulation will generally 
indicate its nature. 

Treatment. — The tumor should be excised, taking care to dis- 
sect out the whole sac, or it will re-form. The cyst itself is 
generally thin and easily ruptured, but it has a firm horny lin- 
ing, which should be seized with the forceps after puncture, 
while the cyst is being separated. In chalazion the incision over 
the tumor should be made on the conjunctival side, so as to 
avoid a visible scar. 

Multiple atheromatous cysts have been reported by various 
observers, but not all of them with quite the same characters.f 

* L. Torok, " Ueber die Enstehung der Atheromacysten (Epidermoide 
Franke)," etc., Monatsh. prak. f. Derm., vol. xii. (i8gi), p. 437. Good 
abs. Brit. Jour. Derm., vol. iii. (1891), p. 365. See also Sutton's 
Hunterian Lectures on Dermoid Cysts, and Reverdin, who analyzed 
thirty-two cases in Rev. Mdd. de la Suisse Romande, March 15, 1887. 

fjamieson, numerous cutaneous cysts, Edin. Med. Jour., vol. xix. 
(1873), p. 223. Maclaren, loc. cit., vol. April, 1887, p. 932. Chiari, 
Vienna corr., Brit. Med. Jour., April 12, 1890; also paper on " Atheroma- 
cysts," Inter. Cong. Berlin, 1890. Dubreuilh, " Kystcs graisseux sudori- 
pares," Archives cli7iiques de Bordeaux, 1896, No. 9. Bocellini, " Beitrag 
zur Lehre von den multiplex follicularen Hautcysten," Archiv f. Derm. 



SEBACEOUS CYSTS. 1127 

Dubreuilh and B. Auche described a case in a man of seventy- 
seven years, in whom there were tumors from a hemp seed to 
a pea in size, round, defined, firm, subcutaneous, but adherent, 
or slightly projecting. They were the color of the normal skin, 
unless very superficial, and then gray or yellowish, soft, pasty, 
or semi-fluctuating. On puncture a soft, whitish, buttery mass 
or a yellow, oily fluid escaped, consisting of 72 per cent, of 
fat, 19.5 of water, and 8 of divers residues. Under the micro- 
scope there were only fat and a few multinucleated cells. 

They were in all regions, but chiefly on the trunk, in masses 
in the axillae, many on the scalp, where they resembled wens, 
and a few on the limbs, but the palms and soles were free. 

Microscopically they were found to be thin-walled cysts lined 
with flat epithelium, and derived from the sweat glomerulus, 
and they therefore called them sudoriparous flat cysts. A sim- 
ilar case in a young man, set. twenty-one, was shown by Pringle 
at the Dermatological Society of London in 1898. In this case, 
when the cyst was pricked with a pin a turbid oil flowed out. 
In Bocellinfs case, which was clinically very similar, in a man, 
set. forty, the tumors were from a hemp seed to a bean or 
larger in size, contained olein and palmitin, and were clearly of 
sebaceous origin, the sweat coils taking no part in them. 

Jamieson and Maclaren have also had cases with 250 and 
150 tumors respectively. In Jamieson's case the contents were 
a turbid, brownish liquid, and he considered them sebaceous. 
Hebra and Rayer are said to have had cases, but they were 
different from the above. In Chiari's case, a man of seventy- 
four, they were innumerable, and he pronounced them to be 
true retention cysts, finding, like Bocellini, a horny plug; he 
also found growing hairs and epidermic cells. The obstruction 
is at the exit of the duct, and the cyst is found there, and not in 
the gland itself. 

Dermoid cysts * of the skin are generally single. Multiple 
dermoid cysts are very rare. They are all remarkably — in fact, 

m. Syph., vol. xlv. (1898), p. 81; references. Unna's " Histopathology," 
p. 891. 

* In the Brit. Med. Jour., February 18, 1888, Sibthorpe reports and 
figures a case of congenital pilo-sebaceous cysts as large as a cocoa-nut 
on the front of the scalp. 



1 1 28 DISEASES OF THE SKIN. 

as a rule, indistinguishably — like fibroma tumors, from a pin's 
head to a hazelnut in size, until excised, or at all events 
incised, when sebaceous-looking matter escapes. In a case of 
Sangster's, reported by Pollitzer,* although most of them were 
like fibroma nodules, and therefore the color of the normal 
skin, those over the mastoid process and clavicles were of a 
lemon yellow, and were generally thought to be xanthoma until 
they were excised, and Pollitzer found that they were typical 
dermoid cysts, the wall presenting a well-marked papillary 
layer, the contents made up of cornified and degenerated epi- 
thelium and detritus, and in most cases a coil of hair and brown- 
ish or black pigment. Their numbers and benignity forbid 
treatment, unless they are in an awkward or unsightly position, 
when they might be excised. 

Follicular Disease of the Scalp. In Guy's " Hospital Re- 
ports " Edward Cock,f and subsequently Goodhart, published 
a series of cases of tumors of the scalp which ulcerated and 
in some cases fungated, and were supposed to be derived from 
the sebaceous follicles. A still more extensively fungating 
tumor is published by Hutchinson, supposed to be secondary 
to a sebaceous cyst. These growths were chiefly situated on 
the crown of the head, but may also come elsewhere about the 
head and face. Thus, one of Cock's cases was on the abdomen, 
but it grew from a mole which was abraded. Goodhart exam- 
ined the tumors, and found them to be mainly composed of 
epithelium, with imperfect septa of ill-developed fibrous tissue. 
They all seem to start from sebaceous cysts, and are, in spite 
of their epithelial structure, evidently benign. Rivington re- 
moved the very large fungating growth reported by Hutchin- 
son, chiefly with Paquelin's cautery. The operation was at- 
tended with profuse hemorrhage, but there was no recurrence 
five years later. 

Ballyntyne J records two cases of congenital growths on the 

* Pollitzer, Amer. Jour. Cut. and Ge7i.-Ur. Dis., vol. ix., August, 1891; 
and Brit. Jour. Derm., vol. iii. (1891), p. 398 — also referred to under 
" Xanthoma." 

f Guv's Hospital Reports, 2d series, vol viii., Part I., 1852, p. 151, 
several colored illustrations, ibid., 3d series, vol. xviii., 1873; Hutchinson's 
Archives, vol. ii.. No. 8, 1891, Plate XXIX. 

% Brit. four. Derm., November, 1897, vol. ix. p. 421. 



MILIUM. 1 129 

scalp which histologically were acanthomata. There was every 
stage of development of sebaceous glands, but only traces of 
the sweat glands and no hairs. The tumor in one case was of 
the size and shape of a child's thumb. Ballantyne suggests that 
an adherent amnion early in fetal life might have led to its 
formation. 

MILIUM.* 

Deriv. — Milium, a millet seed. 

Synonyms. — Grutum; Strophulus albidus; Acne albida; 
Tuberculum sebaceum. 

Definition. — A small pearly-white sebaceous tumor, situated 
just below the epidermis. 

Symptoms. — Alilia are situated chiefly upon the face, especially 
upon the forehead, orbit, and cheeks; they are generally about 
the size of a millet seed or smaller, and occasionally as large as 
a small pea; they may be in small or large numbers, are quite 
white when small, and may be translucent, spherical in shape, 
quite superficial, form slowly up to a certain size, and then 
remain stationary for years. 

Variations. — As a rule, they have no special arrangement, but 
I have once seen them arranged symmetrically on the " clown- 
patch " of the cheeks in a young woman in the same way as will 
be described in comedones, and groups on the inner canthus 
are common in elderly persons. Occasionally they may be seen 
in other parts of the body, such as the scrotum and penis. 
Here, and on the eyelids, they coalesce into comparatively large 
flattish tumors from a pea to half a bean in size, assume a yel- 
lowish color, and may become very hard from the deposition of 
calcareous salts, chiefly phosphate, with a little carbonate of 
lime, and constitute then the so-called cutaneous calculi.j A 
case of osteosis of the epidermis of the sole is recorded by 
Warren Coleman. \ An extreme case of milium-like condition 

* Author's Atlas, Plate LXXXIII., Figs. 1 to 4. 

f Barlow met with concretions of this kind on the abdomen, and Foster 
of Boston is quoted by Duhring as having met with one on the face of a 
young woman, where it formed a small, oval, hard tumor. 

t Amer. Jour. Cut. Dis., vol. xii. (1894), p. 185. 



n 3 o DISEASES OF THE SKIN. 

of the red part of the lips was recorded by Fordyce,* yellowish 
dots and streaks appearing in close aggregation in vertical lines. 
They were, however, not true milium, but due to keratohyalin 
change in the epidermic scales. Minor degrees of it are not 
uncommon. 

Etiology, — Milia are common in young infants (strophulus 
albidus of Willan), probably from overstimulation of the skin 
by being held too closely to the mother. They may, however, 
be present from birth, and are then of embryonic origin. They 
are most common in young adults, frequently in association 
with acne vulgaris, and sometimes follow pemphigus, forming 
small groups or single spots on the site of the bulla. Less fre- 
quently they may be seen after superficial inflammation from 
erysipelas, or cicatrices after atrophy or ulceration, as in lupus 
and syphilis. They are always present in the rare lymphangioma 
tuberosum multiplex either on or between the lesions. Fre- 
quently there is no assignable cause. 

Pathology. — They are usually considered to be due to reten- 
tion of secretion in some of the acini of a sebaceous gland, or 
to be undeveloped glands; but Robinson f of New York thinks 
that they are of two kinds, of which one consists of " miscarried 
embryonic epithelium from a hair follicle or from the rete," 
which contains no fatty epithelium and has no duct; the other 
has a duct and is really a deep-seated comedo, the contents con- 
sisting of fatty epithelium and cholesterin. 

Diagnosis. — The milium masses on the eyelids of elderly peo- 
ple may be mistaken for xanthoma (see that disease for the marks 
of distinction). The usual white globules are quite unmis- 
takable. 

Treatment. — Having no duct, an incision should be made over 
them, and they are readily shelled out. A touch of iodin tincture 
may be applied to the sac if they recur. Hardaway recommends 
electrolysis by passing a fine needle, connected with the negative 
pole of the battery, into the little tumor. In infants, the free 
use of soap and water is generally sufficient. 

* Loc. cit., vol. xiv. (1896), p. 413, with colored and microscopic plates. 
Vide Pseudo-Colloid of Lips, p. 758. 
f Robinson's " Manual of Dermatology," First Edit., p. 73. 



MILIUM COXGENITALE. 1131 



MILIUM CONGENITALE (en plaques).* 

I have described two cases of this rare congenital defect, Hans 
Hebra f and Erasmus Wilson J have independently published a 
case each under different names, and Colcott Fox § has shown 
a case at the London Dermatological Society. 

The condition occurs in patches on the head and face; the 
patch is of a pale reddish-yellow, but redder at times; the sur- 
face is finely granular, consisting of closely aggregated pale 
yellow pin's-point papules, the patch as a whole is slightly raised 
upon the surface. The sharply defined border is more raised 
than the rest, the papules are more distinct, and there are many 
comedones on the borders and a few scattered about the sur- 
face. The patches on the scalp are quite hairless. They are 
present at birth, and change very little, if at all, afterwards; 
possibly it may be due to adherence of the amnion at an early 
stage of fetal life, or to a deep-seated intra-uterine inflammation. 

Microscopically I came to the conclusion that the structure 
which I at first thought were sebaceous glands were really 
identical with the milium due to miscarried embryonic epithe- 
lium, as described by A. R. Robinson. 

The structure was made up of nucleated epithelial cells in- 
closed in a fibrous pseudo-capsule, and situated superficially in 
the corium. Nothing can be done unless the lesion is small 
enough to be excised and primary union obtained. 

Hypertrophy of the Sebaceous Glands. || In this affection 
there is an actual increase of gland tissue by multiplication of 
the acini. In old persons it may sometimes be seen on the face, 
especially on the forehead, where slight degrees are not uncom- 
mon, and on the nose. One of the most extensive cases I have 
seen was that of a woman, set. sixty, who had some jaundice, 

* International Atlas, Plate XXX.; one case was previously reported in 
the Clin. Soc. Trans., vol. xiii., 1880, with colored plate. 

\ Hans Hebra, " Congenital Defect of the Cutis," colored plate. 

% Erasmus Wilson, Jour. Cut. Med., No. 2, July, vol. i. (1867), p. 211, 
Nevus folliculosus. 

§ Colcott Fox, Rep. of Derm. Soc. Lond., Brit. Jour. Derm., vol. ix. 
(1897). P- 21. 

II In the previous edition I called this affection "Atheroma cutis," but it 
bad not then been examined microscopically. 



1132 



DISEASES OF THE SKIN. 



probably from carcinoma of the liver. She had been densely 
freckled all her life, the freckling extending down to the lower- 
rib margin in front and all over the back. Besides this, round 
the orifices of all the glands of the whole face were flat, very 
pale yellow accumulations in the form of discs, 1-16 to 1-8 inch 
in diameter, with a minute slightly depressed puncture in the 
center. They were very closely set all over, but discrete, not 
at all raised above the surface, not perceptible to the touch, but 
isolated lesions may be seen in other cases as slightly raised 




Fig. 67. a, yellow nodule consisting of hypertrophied sebaceous gland; 
b, Acinus from a. a, X 1 inch Ross 6 inch tube; 6, X tg high angle 
6 inch tube. 



rather firm nodules. I have seen a very similar condition all 
over the neck of a woman with jaundice and general xanthoma, 
but the lesions themselves were quite different from xanthoma, 
and slight degrees are common when there is no suspicion of 
hepatic disorder. In a lesion from the forehead of an elderly 
man the only changes were great multiplication of the acini of 
the sebaceous glands, and atrophic degeneration of the lanugo 
hair follicide. 

In November, 1895, Dr. Sangster sent a lady, set. forty-one, 
to me of apparently the same affection on the temples and 
cheeks which had been developing from the age of sixteen. 
About a score altogether, they were from a pin's head to half 



COMEDONES. 1133 

a hemp seed in size, raised slightly, firm and yellowish, the older 
ones opaque with minute vessels over them, the smaller ones 
slightly translucent, and all had a slight depression in the center 
and in some there was a plug like that of molluscum con- 
tagiosum, but it could not be expressed. It was found that the 
best way to remove them was to incise them and scrape them 
out with a curette, which was not done without difficulty, as they 
were firmly adherent. They healed without scarring. One near 
the angle of the mouth was excised, and proved to be an 
enormously enlarged sebaceous gland (Fig. 67). Pollitzer's * 
case was of the same character, but was in a vertical linear 
group over the left eyebrow of a man, set. twenty-five, and had 
been developing six or seven years. 

COMEDONES. 

Deriv. — Comedo, a glutton. 

Definition. — Black points or papules formed by sebum and 
horny cells blocking the orifice of the duct. 

This common affection is seen chiefly on the face and back, 
neck and chest. Each comedo forms the well-known black point 
or pin's-point-sized papule so conspicuous on the face of many 
adolescents and young adults, and occasionally in older persons. 
Sometimes comedones contain the acarus folliculorum.j They 
vary in number from one here and there to myriads, peppering, 
so to speak, the whole countenance, but are most abundant on 
the forehead, temples, sides of the cheeks, and the nose. When 
numerous, they are associated with more or less oily seborrhea, 
and as they are very liable to inflammation, acne vulgaris in one 
or other of its phases is seldom absent. They can easily be 
expressed by the nails, looking like a maggot, and on the back 
and chest are often comparatively large, and may be double 

*Pollitzer. A case of adenoma sebaceum. Amer. Jour. Cut. Dz's., 
vol. xi. (1893), p. 475. It is quite different from the classical adenoma 
sebaceum. 

f To see the acarus, ten or a dozen comedones should be taken, and 
teased out in glycerin. They do not appear to have any pathological 
importance in the human subject, but a similar acarus in dogs sets up con- 
siderable inflammation, constituting "follicular mange." 



H34 



DISEASES OF THE SKIN. 



from the fusion of two plugs by suppuration of two adjacent 
follicles with a bridge of skin between the orifices. 

A very remarkable example of scar comedones, in which large 
single and double comedones existed in masses, was shown at 
the London Dermatological Congress in 1896 by Selhorst of 
The Hague in an acneiform nevus.* Thibierge has recorded a 
very similar case. I have seen them very numerous and large on 
the scalp as the result of extensive kerion. De Coquet f records 
an extreme instance on the face, after smallpox. 

Lang showed a case to the Vienna Dermatological Society 
with comedones on the glans penis and prepuce; and besides 
this rare position, there was the additional rarity of atrophic 
scars at the orifice of the follicles. Neumann showed a similar 
atrophic scarring from comedones all over the usual positions 
in a woman. 

The etiology, pathology, and treatment are discussed along 
with Acne Vulgaris. 

Grouped Comedones. These differ from the preceding in 
their position, arrangement, and etiology, and in having no rela- 
tion to acne vulgaris. Thin $ was the first to write about them, 
and I published cases corroborating what he had said, and show- 
ing that further observation by myself and others pointed to 
dyspepsia as the commonest predisposing cause, and that they 
occur chiefly on the cheeks and those parts of the face where 
flushing after meals is most marked. They form symmetrical 
groups of densely crowded black points on both sides of the 
face, and the individual lesions are much smaller and more uni- 
form in size than in most cases of ordinary comedones. There 
is little or no tendency to inflame and suppurate. I have twice 
seen densely crowded comedones on the trunk, but without any 
tendency to group, and associated with suppuration of a large 
number of them. One was in an old man, and they were all 
over the abdomen; the other was a case of Sangster's, which 
he kindly allowed me to photograph — a middle-aged man, in 

*" Nevus Acneiformis Unilateralis," Selhorst, Brit. Jour. Derm., vol. 
viii. (1896), p. 419, with photos. 

f Abs. Brit. Jour. Derm., vol. v. (1894), p. 320. 

% Lancet, October 13, 1888, and by myself October 27 — both papers 
illustrated. See also Wetherell and Sympson, who report single cases in 
vol. i. for 1889. 



COMEDONES. 1135 

whom the upper part of the chest and nearly the whole of the 
back were involved. Large comedones, single or in masses, 
may often be seen in the faces of old persons. They are not 
infrequently massed at the corner of the orbits. These are not 
to be classed with the preceding cases. 

Children. — Hitherto comedones have been considered to be an 
affection not seen before puberty, but in June, 1882, I saw it at 
the East London Hospital for Children in a child aged three 
and a half years. This was soon followed by other cases, and 
similar instances have been met with by other observers, and it 
is now not an uncommon affection among the poor in summer; 
yet it is apparently a new condition, as I know of no previous 
notice of the affection prior to my own.* They appear on the 
upper part of the forehead and corresponding parts of the oc- 
ciput in boys above three, on the temples in girls, and on the 
cheeks in infants, and occasionally in other situations. They 
are usually very densely packed, often grouped, occasionally 
symmetrically, like the adult cases, and give the part a very 
dirty and sometimes black appearance, and seborrhea is often 
present on the head. The contents are rather firmer than usual, 
containing less fat. Most of them do not inflame spontaneously, 
but do so if roughly squeezed or otherwise irritated. 

The condition appears to be excited by warmth and moisture, 
and perhaps by other local irritants in predisposed subjects; it 
corresponds to the position of the cap in boys, and in infants 
appears to be due to their being held closely to the mother in 
nursing. I have seen it from the use of linseed poultices all 
over the back and chest, many of the comedones suppurating 
like ordinary acne. I have also known it to occur simultane- 
ously in several members of a family, and it was stated to have 
attacked a large number in a school, suggesting a bacterial 
source of contagion. Haddon and others have met with similar 
instances pointing to contagion. 

Their chief peculiarities consist in their being apparently due 
to local causes, among which want of cleanliness is the potent 
factor; in their tendency to group and to be more closely set; 
in their involving the hairy scalp ; in their being less likely to set 

*See Lancet, April 19, 1884; also a letter by Julius Csesar, on May 6, 
in the same volume, and an article by Colcott Fox, April 7, 1888. Author's 
Atlas, Plate LXXXIII., Fig. 5. 



1136 DISEASES OF THE SKIN. 

up inflammation, and in their amenability to local treatment. 
Bathing with hot water, followed by friction with a liniment of 
sapo mollis half an ounce, spiritus vini an ounce and a half, or 
in slight cases rubbing in a weak sulphur ointment, or an alka- 
line lotion, such as glycerin of borax one part to three of water, 
are generally sufficient for their removal. A perchlorid of mer- 
cury lotion i in iooo, after soft-soap frictions, is also recom- 
mended. 



ACNE. 

Deriv. — aurr/ or an/A^a point, or, as some think, a f privative, 
and hv£gd 7 to itch. 

Synonyms. — Lat., Varus; Gr., i'ovOoS; Fr., Acne; 
Ger. y Hautfinne. 

Definition. — The term acne is used for the lesions produced by 
inflammation, chiefly pustular, in and around the sebaceous 
glands and hair follicles. 

Under this head are included: (i) Acne vulgaris or adoles- 
centium, with the varieties acne cachecticorum and acne arti- 
ficialis (all sebaceous); (2) Acne rosacea (partly sebaceous); (3) 
Acne scrofulosorum (follicular); (4) Acne varioliformis (follicu- 
lar) ; (5) Acne keratosa (follicular) ; (6) Acne necrotisans (sebace- 
ous). 

Whenever the duct of a sebaceous gland is occluded, inflam- 
mation is very likely to ensue. 

In A. vulgaris the sebaceous secretion itself forms the plug. 
In tar acne, and the acne occurring in those engaged in greasy 
occupations, the tar and fat stop the excretion of the sebum. 

In A. cachecticorum and in the so-called bromid and iodid 
acne, the changes are probably in the blood-vessels; the latter 
and tar acne are described under Drug Eruptions. In A. 
rosacea the sebaceous inflammation is also secondary to the 
blood-vessel alteration, which produces the chief symptoms, 
while the pathology of A. varioliformis is still unsettled. 

Acne is used in a much wider sense in France, being applied 
to many sebaceous and other affections, even when the lesions 
are not elevated into papules and pustules, but this abuse of 



ACNE VULGARIS. 1137 

the term is gradually being given up. A reference to the Index 
will show into what category these disused synonyms should 
be placed. 

ACNE VULGARIS.* 

Synonyms. — Acne adolescentium; Acne disseminata; Stone pock. 

Definition. — Inflammation of the sebaceous glands due to re- 
tained secretion, occurring chiefly in young people. 

A. vulgaris is a very common disease in adolescents, though 
it does not form more than 2 1-2 per cent, of all forms of skin 
disease which come to a special department, but in private prac- 
tice it forms six per cent. It is of all grades of severity, from 
one or two small pustules at a time up to thickly aggregated 
papules, pustules, and nodules in all stages of development and 
retrogression. While each stage of development has received 
a different name, A. cachecticorum is the only kind which is 
entitled to a separate designation and description. 

Symptoms. — The disease does not occur before puberty; it is 
common from then onwards for about ten years, and declines 
almost to a vanishing point at the age of thirty. It is limited, in 
the great majority of cases, to the face (chiefly at the sides and 
on the forehead, but it does not go back into the scalp), the 
neck, chest, and back, chiefly about the shoulders, and its extent 
is largely dependent upon the number of comedones present, 
round which the inflammation commences, and forms at first a 
red papule, soon becoming a pustule on a red raised base, with 
a central black point (A. punctata), or if the plug is within the 
gland, instead of at the orifice, there is a pustule without an 
obvious comedo (A. simplex). When the pustule with its red 
base enlarges to the size of a hemp seed or small pea, it is 
A. pustulosa, and when the inflammation extends to the tissues 
round the gland, or begins deeply so as to form a hard, pea to 
a bean-sized, deep red or purplish nodule, which subsequently 
softens in the center, but seldom ruptures spontaneously, as it 
has no orifice, it is A. indurata. But all these names are su- 
perfluous, and will doubtless be dropped eventually. These 
lesions, although bilateral, are not symmetrical, are discrete, and 
not grouped in any way; hence the term disseminata. The 
* Author's Atlas, Plate LXXXIV., Fig. 1. 
72 



1138 DISEASES OF THE SKIN. 

process may stop short at any of these stages, especially if the 
contents be evacuated without violence; but as fresh lesions fre- 
quently form, and others involute or discharge, all phases of the 
eruption may be seen simultaneously in one patient. A. indu- 
rata, however, occurs chiefly in strumous subjects, and leaves 
livid indurations, which slowly disappear. The small, superficial 
pustules may leave no scars, but the larger and deeper lesions 
lead to considerable scarring and much consequent disfigure- 
ment, and on the chest and back small keloid tumors sometimes 
develop in the cicatrices. In some instances the comedones are 
numerous, but only a few inflame; in others, a large proportion 
go on to acne lesions. Where the comedones are abundant, 
more or less seborrhea, especially the oily form, is present, and 
the complexion is thick and muddy. Beyond the disfigurement 
and the tenderness of the large pustules the eruption produces 
but little inconvenience. 

Variations. — A. vulgaris occasionally persists after thirty, and 
may exist to some extent throughout life; the back and chest 
are then considerably involved, with large indurated nodules,, 
and I have seen the whole back one mass of confluent scars, 
pustules, and large comedones. Ord showed a case at the 
Clinical Society in April, 1892, in which the comedones and pus- 
tules ran round the body in a band, but not in the course of 
nerves. In a case of Lewin's of Berlin pigmentation of the site 
of the acne pustules occurred. Under adverse conditions the 
disease may generalize as in the case of a clerk,* set. twenty-one,, 
who was always subject to A. vulgaris in the usual positions^ 
and after overwork and loss of rest, the whole face, trunk, and 
limbs to the elbows and knees were in four days thickly cov- 
ered with red papules and pustules of the usual acne type, each 
pierced by a hair, or with sebum at the orifices; the glands also 
in the axillae and groins were enlarged. 

This exceptional generalization of A. vulgaris constitutes 
A. cachecticorum, which is not limited to certain regions, but 
occurs anywhere, except on the palms and soles. The lesions 
are not due, as a rule, to retention of the secretion, and there 
are therefore no antecedent comedones ; hemorrhages frequently 
take place into the pustules, which have then a livid border and 
leave long persistent, purplish scars behind them. In this form 
* Private Notes, 1880, p. 101. 



ACNE VULGARIS, 



ll 39 



it may be seen sometimes during recovery from scurvy, and I 
have seen a few cases in middle-aged and elderly people due to 
semi-starvation.* It may also in rare instances attack the folli- 
cles f of the limbs without any cachexia or traceable cause, of 
which I have seen a few instances. 

Etiology. — Disseminated comedones and acne may be consid- 
ered as almost identical as regards etiology; males and females 
are equally liable to them, and in hospital practice three-fourths 
of my cases were between the ages of fifteen and twenty-three, 
the extremes being thirteen to forty-four years; but one private 
case, a diabetic man. was sixty-seven years of age. Prac- 
tically the disease is only prevalent from thirteen to thirty. 

If Sabouraud's views are correct, that the seborrheic microbe 
is the cause both of seborrhea and the comedo, it is obvious 
that the presence of seborrhea capitis must play an important 
part in the etiology of the comedo and its sequence the acne 
pustule, and, as a matter of fact, they are generally concomitant. 
Indeed, Sabouraud says that there can be no acne without pre- 
liminary oily seborrhea, though if in excess it prevents sec- 
ondary infections. On the other hand, while seborrhea may be 
present at almost any age, acne vulgaris and the comedo cease, 
as a rule, about thirty or earlier. Predisposing conditions are 
puberty and the physiological pilo-sebaceous activity which 
characterizes that period. 

The frequency of acne in people with a thick skin and a slug- 
gish circulation points to these also as factors. Local causes, 
such as cold winds, the use of irritating cosmetics, working with 
tar, paraffin, chlorin makers, t etc., and insufficient washing, 
play a certain part, either by plugging the orifices or irritating 

♦One of these, a well-marked case, was published by Tilbury Fox in the 
Lancet of April 5, 187S. A very severe and curious form in a boy of 
fourteen is published by Bronson in Amer. Jour. Cut. and Gen.-Ur. Dz's., 
vol. vii. (iSSg), p. 401. Kaposi had a case of apparently ordinary acne of 
the trunk, which left slightly depressed discoid scars, from a lentil to an 
inch and a half in diameter; some of them were pigmented, and granula- 
tion tissue was found under some of the crusts. He called it acne 
cachecticorum Ann. de Derm, et de Syph., vol. iii. (1892), p. 316. 

t Author's Atlas, Plate LXXXIV., Fig. 2. 

J By electrolysis from chlorid of sodium, Sabouraud has proved that 
the plugs are ordinary comedones and contain the special micro-bacillus. 
The acne is severe. 



n 4 o DISEASES OF THE SKIN. 

the glands; but far more important is reflex hyperemia, pro- 
duced by derangement of the alimentary canal, especially con- 
stipation and dyspepsia, which were present in a large propor- 
tion (more than half of my cases); uterine and ovarian dis- 
orders, especially those which lead to catamenial derangement, 
are also causes, and, even when this function is undisturbed, 
the eruption often undergoes exacerbation immediately before 
a period. All debilitating causes predispose to acne, of which 
anemia and chlorosis, too rapid growth, and perhaps masturba- 
tion, may be especially mentioned; mental and physical exhaus- 
tion have preceded fresh outbreaks in many cases; struma and 
scurvy not only cause, but modify, the kind of inflammation, 
leading to freer suppuration than usual. Diet has some effect, 
beer and the excessive consumption of sweets are predisposing 
causes, but this may be because so many acne patients have 
imperfect digestions. 

Pathology. — According to Unna the comedo is the product of 
hyperkeratosis extending from the surface to the mouth of the 
follicle, and consists, therefore, chiefly of horny cells, mixed 
with normal sebum and not, as used to be thought, the result 
of abnormal secretion. The black head is the result not of dirt, 
but of degeneration of the compressed horny cells. Sabouraud's 
observations go to prove that the comedo is the result of bac- 
teriological action, viz., that of the seborrheic bacillus which 
he has rediscovered, and that practically a comedo is in the main 
a " cocoon," as he calls it, of seborrheic bacilli, of course with 
horny and fatty cells and rudimentary hairs. Unna recognizes 
flask bacilli (spores of Malassez), and a diplococcus which he 
regards as the cause of seborrheic eczema; but these he con- 
siders accidental, as they are in the upper part of the comedo, 
and not invariably present, while another bacillus which is con- 
stant is situated in the lowest part of the comedo. The last 
are a third to half a pi broad by I 1-4 pi to 1 1-2 pi long, with 
very irregular arrangement, though sometimes in a thread of 
three or four. They are, he considers, mucin-producing bacilli 
and the cause of suppuration, the presence of staphylococci 
being unnecessary and exceptional, and if present they are ac- 
cidental and only superficially situated. If the bacilli get free 
into the supracomedo horny layers, a superficial acne pustule 
results. If the comedo is open at the bottom they get deep 



ACNE VULGARIS. 1141 

into the follicle and the connective tissue round it, and an acne 
indurata ensues. The more superficial form leaves no perma- 
nent scar, the deeper one does either with depression or with 
a permanent increase of the connective tissue. 

Such is Unna's explanation of the phenomena of acne, and 
it sounds feasible enough, but if Sabouraud is right, that the 
seborrheic micro-bacillus is the cause of the comedo, the role 
of Unna's bacillus is at a discount, unless he and Sabouraud 
are describing the same organism with a different name. I do 
not pretend to decide between them, but Hodara's * inde- 
pendent observations support Unna's. He found in an early 
stage of the comedo Unna's bacilli in small foci without any- 
other organisms, while in comedones without acne they were 
quite absent. Sabouraud ascribes the inflammatory reaction 
to the secondary invasion of staphylococci producing a gray 
culture, apparently the morococcus of Unna. Gilchrist f in 
1899 described a special pyogenic short, thick bacillus, which in 
cultivations became longer, thicker, and showed division, and 
various branching forms were observed in older cultures. He 
discredits Lowry's observations on ten patients in which he 
found staphylococcus pyogenes albus. His own appear to have 
been carefully made on ninety-six pustules from fifty-five 
patients. 

On the whole, the tendency of the evidence is in favor of a 
special pyogenic organism, but there may be a " tertiurh quid "; 
e. g., in " tar acne " the bactericidal action of tar is against the 
invocation of bacilli as the cause of suppuration, which appears 
to be mechanical. In like manner the effect of the comedo might 
also be largely mechanical, and most if not all of the micro- 
organisms found in the comedo may be secondary, and as harm- 
less by themselves as a cause of the acne pustule as the demodex 
folliculorum which is so often present, but has no pathological 
significance. 

Clearly the subject as a field for investigation is not yet 
exhausted. 

Diagnosis. — The age of the patient, the dissemination of the 

*Hodara, good abs. in Annales de Derm, et de Syph., vol. v. (1894), p. 
721. 

f Gilchrist, vol. ix., Johns Hopkins Hospital Reports, p. 420, "Research 
upon the Etiology of Acne Vulgaris." 



1 142 DISEASES OF THE SKIN. 

lesions on the bust only, as a rule, the acute course of the indi- 
vidual lesions, the chronicity with exacerbations of the disease 
as a whole, the anatomical seat of the pustule, together with 
the presence of comedones, generally prevent any trouble in the 
diagnosis. The diagnosis of the so-called drug acnes is dis- 
cussed with the drug eruptions. 

A. rosacea occupies only the middle two-thirds, while A. vul- 
garis predominates on the sides of the face. A. rosacea patients 
are older, as a rule past thirty, and the sebaceous inflammation 
is only a part of the disease, the main feature being diffuse 
hyperemia of the face and dilated vessels. 

Acne varioliformis has a special localization in the upper part 
of the face and the scalp, the latter is a position never affected 
by acne vulgaris, and the smallpox-like scars of the former are 
very distinctive. 

When A. vulgaris is generalized, the circumstances under 
which this generalization occurs and the anatomical seat of the 
lesions will guide to a correct conclusion. The acute cases which 
somewhat resemble variola may be distinguished by the dura- 
tion of the eruption, the absence of constitutional symptoms, 
and the absence of the eruptions from the forearms and wrists. 

The syphilitic eruptions which resemble acne tend to group, 
which A. vulgaris seldom does. 

Prognosis. — The ultimate result in all but a very few is spon- 
taneous recovery. Most cases are quite well before twenty-five 
years of age, and few last beyond thirty. Treatment may, how- 
ever, much shorten the period, and either completely cure or 
greatly ameliorate it. Success depends in most cases on the 
possibility of detecting the cause, and being able to remove it; 
and the apparently causeless cases are generally the most obsti- 
nate. Where the suppuration is deep or very free, more or 
less scarring results, but the majority of the lesions are super- 
ficial, and leave no permanent trace behind. 

Treatment. — The treatment of acne must be both general and 
local; for although local treatment alone will remove any 
eruption that may be present, in many cases, only general treat- 
ment, judiciously planned, and perseveringly carried out for a 
considerable period, will prevent its recurrence. Where there 
are no indications for general treatment, seborrhea capitis is 
often the condition which requires removal. Many dermatolo- 



ACNE VULGARIS. 1143 

gists of the present day, having regard to the microbic origin 
of the comedo, advocate local treatment only; but considering 
that the majority of people do not get comedones and acne at 
puberty, and that everyone must be exposed to so common a 
microbe as that of seborrhea, there must be a suitability of soil 
present also, sometimes no doubt congenital, but in other cases 
acquired, and, as experience shows, capable of modification by 
general treatment. 

The measures to be adopted are hygienic, dietetic, and medi- 
cinal, and should aim at the general invigoration of the patient 
and the removal of digestive and other derangements; cold 
sponging of the whole body every morning, as much outdoor 
exercise as the patient's strength admits of, at the same time 
avoiding or protecting the face against cold winds, and regular 
and early hours are generally necessary. The aim should be 
to do all that is possible to avoid gastro-intestinal fermentation. 
The diet should be unstimulating, and where there is the least 
tendency to indigestion, highly seasoned dishes, pastry, sugar, 
and indigestible food generally, together with beer, champagne, 
and the stronger alcoholic drinks, should be avoided altogether, 
or taken very sparingly. Intestinal disinfectants, such as salol 
or benzo-naphthol in five-grain doses after meals are often use- 
ful. A furred tongue with prominent papillae and constipation 
are very often present, and a mixture of soda bicarbonate, mix 
vomica, glycerin, and dill or peppermint water and (F. 8-10), are 
very useful. Cascara in some form may be taken separately as 
required, or saline aperients, seidlitz powders, or mineral 
aperient waters such as Hunyadi Janos, Apenta water, etc., may 
be indicated. 

When there is anemia with constipation, which are frequently 
associated, the elder Startin's mixture of iron and aperients 
(Mixtures, F. 16), etc., is most useful; or if constipation is ab- 
sent, tonic mixtures, such as Parrish's food, Easton's or Fel- 
lowes' syrup, the mineral acids, and nux vomica (F. 11 and 12), 
may be suitable. Small doses, TfXij or TTLiij, of liquor arsenicalis, 
may be given for its tonic rather than for its direct effects on 
the skin, though it also appears to be directly beneficial in some 
cases, where the inflammation tends to stop short of suppura- 
tion, but it must always be given cautiously, or, by upsetting 
the digestion, it will aggravate the eruption. In the strumous 



1 1 44 DISEASES OF THE SKIN. 

diathesis so often present, cod-liver oil with the syrup of the 
iodid or other form of iron is essential, and the oil is often ad- 
vantageous in other cases, as soon as the digestive organs will 
tolerate it. Of the more direct remedies sulphid of calcium, 
a quarter to half a grain three times a day, is indicated, when- 
ever there is a tendency to free suppuration, and glycerin in 
half-ounce doses is recommended by Desguin of Antwerp, Bulk- 
ley, and Gubler as generally useful in acne. 

Locally, when comedones predominate over the inflammatory 
lesions and the skin is not very delicate, medicated soaps of 
various kinds are useful. A powerful one I often use is sapon. 
mollis, spirit, vini rect. aa 5ij> thymol 5j. Moistened flannel 
is dipped in the liniment, and then rubbed firmly on where the 
comedones are most abundant. It is then rinsed off with warm 
water and calamin lotion painted on if irritation is produced, 
or a resorcin ointment 5ss to 5j rubbed in if there is not. There 
are many medicated soaps in the market of more or less value, 
especially the Eichoff series, some of which are mentioned in 
the Formulary in the Appendix, but none better than the above. 
Hebra's plan, much followed in Germany, was to rub on his 
spiritus saponatus alkalinus and leave it on. This has a discu- 
tient action which is of undoubted value, but disables the patient 
from his occupation or society, and is seldom practicable in this 
country, and must be reserved for severe cases when the patient 
is obliged or is willing to lie up. 

The same may be said of the other German discutient treat- 
ment with naphthol, resorcin, and sulphur paste. When, how- 
ever, the patient can be under close supervision, as in a nursing 
home, it may be usefully employed, as it shortens the time of 
treatment. 

Bathing with water as hot as it can be borne, or holding the 
face over steam from a bronchitis kettle, or Lee's steam draught 
inhaler, is a good preliminary to the pressing out of the come- 
dones, which prevents the development of pustules if done 
gently, but undue force sets up the inflammation that these 
various methods are designed to avoid. Many instruments have 
been devised to facilitate their removal, one of the best of 
which is a modification of Clover's acne presser (Fig. 68). The 
notch is placed over the comedo, and moderate pressure with 
a shaking motion expresses it. A watch-key may also be used, 



ACNE VULGARIS. 1145 

but the sharp edges make it more painful, and likely to bruise 
the tissues without great care. Where the comedones are in 
great numbers, as on the back, curetting is valuable; it cuts off 
the horny covering of the comedo and facilitates expulsion. 
For acne of the back friction with a towel dipped in sea-water 
is beneficial. Massage of the face after steaming may be use- 
fully employed in sluggish skins. To get rid of the double 
comedo the bridge of skin between them should be divided and 
the comedo scooped out. 

When suppuration has occurred the earlier the pustule is 
punctured the less likely is there to be a scar; and even when 




Fig. 68. — Clover's acne presser, as modified by myself. The shank is 
curved near the cup. 

there is no pus visible on the surface a deepish puncture of the 
red papule will generally give exit to a little bead of it mixed 
with sebum. In A. indurata the incision should be more free, 
or multiple punctures, followed by bathing with hot water to 
encourage bleeding, is a good plan. The thickening of the tis- 
sues often left by acne induration is absorbed more quickly by 
the application of Beiersdorf's paraplast. hydrarg. fifty per cent., 
acid, carbolici 7.5 per cent. Leslie Roberts advocates elec- 
trolysis to each nodule. After the incision the puncture should 
be sterilized either by rubbing in iodoform or europhen, or, still 
better, by syringing out with a 1 in 40 solution of carbolic acid, 
using a hypodermic syringe. At first, every fresh tender papule 
should be done every day; but very soon twice a week, then 
once a week, will be sufficient. If the patient has the courage 
and perseverance to go through with this treatment, there is 
no doubt that bad cases improve more rapidly by it than by any 
other. Kaposi's lancet is made for the patient's own use, but 
very few have the knowledge and resolution to use it effectually. 
Instead of using steady pressure, they give themselves a sudden 
superficial prick, and fail to evacuate the pus. 

Where the knife is dreaded, each nodule mav be touched once 



n 4 6 DISEASES OF THE SKIN. 

or twice a week with strong carbolic acid (ninety-five per cent.), 
or the acid nitrate of mercury diluted i to 4; care must be taken 
in using the acid nitrate of mercury, or scarring will ensue. 
Another plan (Stelwagon's) is to apply a one per cent, to four 
per cent, solution of bichlorid of mercury, three times the first 
day, and every three or four days subsequently. Sulphur in 
some form is useful in nearly all stages of acne; the precipitated 
sulphur may be scented, and applied with a powder puff three 
or four times a day; a lotion of oij of sulphur sublimat., ether., 
spirit, vini and glycerin, with aqua calcis and aq. rosse, of each 
§iv, may be applied at intervals; or an ointment of precipitated 
sulphur 5j to oiv to the §j oi lard or vaselin; or a saturated 



Fig. 69. — Kaposi's acne lancet. 

solution of sulphur in vaselin may be used; hypochlorid of 
sulphur 5j to the 5j of benzoated lard, is one of the best, but 
must be always freshly made, and kept in a stoppered bottle; 
sulphid of potassium 5j to a quart of water is a good, but dis- 
agreeable remedy, and is much improved by adding oj of tinc- 
ture of benzoin; or potassium sulphid and zinc sulphate of each 
5j and aq. rosae ^v is a favorite formula in America; iodid of 
sulphur gr. 10 to gr. 60 to the §j, or sulph. prsecip. and alcohol 
(Hebra), are other forms of using sulphur. 

When the hyperemia is very great, soothing remedies may 
be necessary at first; a bismuth or calamin lotion, with a quarter 
of a grain of hyd. bichlor. to the 5j is good; this may be used 
on the day after the more stimulating applications, and partially 
conceals the eruption in addition to its sedative effect. For 
obstinate cases of A. indurata, hyd. iod. gr. 2 to gr. 15 to %], 
or hyd. biniodid. gr. 5 to gr. 20 to %] of benzoated lard, may be 
cautiously applied. These are only samples of a host of local 
remedies, all more or less useful in properly selected cases. 



ACNE ROSACEA. n 47 



ACNE ROSACEA.* 

Synonyms. — Rosacea; Bacchia rosacea; Gutta rosacea; Gutta 
rosea; Acne erythematosa; Fr., Acne rosee; Couperose; 
Ger., Kupferrose; Kupferfinne; kupfriges Gesicht. 

Definition, — A chronic congestion of the face, leading to per- 
manent vascular dilatation, with more or less secondary sebace- 
ous inflammation. 

Acne rosacea is a rather common disease, though it does not 
form more than two per cent, of all cases in hospital and six 
per cent, in private practice.* It is limited to the face, usually 
the middle two-thirds of the long diameter, and is of varying 
intensity, three grades of which may be conveniently distin- 
guished; but all cases do not pass through them, as the condi- 
tion may be arrested at any point. 

Symptoms. — At first, there is simply temporary flushing after 
meals, exposure to changes of temperature, or, in women per- 
haps, just before the catamenial period. When this has gone 
on unrelieved for some time the face becomes permanently red, 
and many small vessels become prominent and varicose. The 
change is limited to the middle two-thirds of the face, affecting 
the cheeks, nose, chin, middle of the forehead, and occasionally 
the front part of the scalp in bald people, or to one or more of 
these regions, but the nose seldom escapes. The border of the 
redness is ill-defined, the vascularity can be obliterated for a 
moment by pressure, and the hyperemia being largely passive, 
the circulation in the skin vessels is sluggish. When very 
prominent, there is often seborrhea nasi; many ducts on the 
nose are plugged with sebum, imparting to it a greasy feel, and 
when it has lasted for some time, in spite of its fiery redness, 
it is often colder than normal to the touch. Distended varicose 
vessels appear on the sides and tip of the nose and on the cheeks, 
and the disease may go no further; but more frequently, after 
a variable time, usually months or years, but sometimes almost 

* Author's Atlas, Plate LXXXV., Fig. i. An average case. 

f Bulkley's statistics in his monograph on acne are i in 70 in hospital 
practice, 6 per cent, in private practice, and about 3 per cent, in hospital 
and private practice. 



n 4 8 DISEASES OF THE SKIN. 

simultaneously with the permanent hyperemia, papules, pustules, 
or nodules develop, which can generally be shown to have their 
origin in the sebaceous glands. This constitutes the second 
stage. In women and in the majority of men, although there 
are fluctuations, there is no material increase of the disease 
beyond this stage; but in chronic drinkers, especially if they are 
also exposed to the weather, e. g., coachmen, there is an increase 
of connective tissue round the vessels, leading to permanent, in- 
tensely red, but non-inflammatory, nodulated thickening of the 
tip and sides of the nose, expanding it both laterally and longi- 
tudinally (A. hypertrophica), while in extreme cases these 
excrescences develop into pendulous stalked tumors (rhino- 
phyma), overhanging the mouth and lower parts of the face. 
These extreme developments are very rare ; I have met with one 
as large as a good-sized pear, and they may be larger; in another 
case, very large and lobulated, the patient, an alcoholic cabman, 
said the growths began shortly after being kicked in the face 
by a horse. Probably some determining factor which interferes 
with the lymphatic circulation is required, as alcoholic coach- 
men are common, and rhinophyma is rare. Hans v. Hebra * 
went further, and regarded it as a disease independent of A. 
rosacea, and saying that it may arise in temperate men and total 
abstainers. While it may be admitted that alcohol plus ex- 
posure is not the only cause, it cannot be disputed that the 
extreme forms are more frequently met with in chronic alco- 
holism, and minor degrees of hypertrophic noses are notori- 
ously so, but I have seen a case in an excessive tea-drinker who 
had been a total abstainer for twenty years. 

According to F. Hebra A. rosacea is, in spirit-drinkers, more 
frequently limited to the nose, and consists of vascular dilatation 
and seborrhea; while in wine-drinkers, the redness is diffuse 
and seldom limited to one region, and the whole face is bloated; 
and in those who affect beer cyanotic thickening with small 
nodules and pustules is more frequent. These distinctions are 
probably fanciful. Another form of hypertrophic A. rosacea 
occurs on the forehead, between the brows' in very rare in- 
stances. Deep sulci where the natural wrinkles would be, are 

*" Rhinophyma," Viertelj.f. Derm. u. Sypk., 1881, Heft iv., with 
histological plate. It is depicted in F. Hebra's Atlas, Heft vii. Tafel 6, 
and the case of the cabman is published in my Atlas, Plate LXXXV. 



ACNE ROSACEA. 



1149 



produced by the thickening of the skin on each side of them 
simulating the leonine appearance of the nodulated leper. Bes- 
nier * records an extreme instance in an alcoholic shoemaker. 
I have seen a case of moderate degree. A similar condition is 
met with in the lymphatic form of mycosis fungoides. 

In a lady f of thirty-four the disease began as a small patch 
of vascular papules and pustules over the zygoma, and spread 
downwards over the whole cheeks in about six months, and 
twelve months later the whole of the cheeks were swollen 
purplish-red, and covered with closely-set hemp-seed-sized 
superficial pustules, with a moderate number of large comedones 
interspersed. The nose was quite free, but there was a 'slight 
degree of it between the brows. The disease began in the sum- 
mer, and although there was moderate dyspepsia, not enough 
to account for the condition. Great improvement was effected 
by scarification. I have had a similar case also in a lady of 
thirty. 

Rosacea acuminata is the name I venture to give to a hith- 
erto undescribed variety of eruption of the face. It is rare, 
but I have now notes of seven cases, and the papular elements 
are, I believe, seated in the sweat pore area, though I have no 
anatomical proof of this. It consists of minute or pin's-head 
convex red papules, most abundant on the cheeks, but they may 
also occur on the forehead and lower part of the face. A sero- 
pustular apex is sometimes present on the papules. The papules 
may be sparse or numerous, but are not grouped in any way — 
general congestion of the face is not usually present. 

All but one occurred in young ladies between twenty-one and 
thirty-five, and although flushing after meals and other dys- 
peptic symptoms were present in a slight degree in the majority, 
I think dyspepsia played only a small part in the etiology. In 
two there was a strong probability of its having been excitecl. 
by chills after being hot. Exposure to cold winds, and fire or 
sun heat, always aggravated the eruption. One lady, set. sixty- 
two, had it associated with marked dyspepsia and rosacea, but, 
as in all the rest, the nose was spared. Ichthyol Tt\v ter die 
succeeded in most of the cases, in removing the eruption, some- 

*St. Louis Atlas, Plate VI., Fig. 2. 
f Note Book I. p. 237, private cases. 



n 5 o DISEASES OF THE SKIN. 

times after other treatment had been tried and failed; but all 
the cases ran a slow course, with a tendency to recur after ex- 
posure to sun or wind. Fox and Galloway have shown cases at 
the Dermatological Society, and Fox recommended sulphur 
ointment gr. xx to the §j, which was used successfully in Gallo- 
way's case. 

Etiology. — The disease is seen much more frequently in women 
than in men (five to one), but the difference diminishes after 
forty years of age. The age of onset, for the bulk of the cases, 
is over twenty-five years, beginning, in fact, at the age when A. 
vulgaris is ceasing to appear. The extremes I have met with 
are, sixteen years in a female and seventy-two years in a male, 
and Bulkier met with one set. fourteen years and another set. 
eighty-four. Comby,* however, breaks the record with a rickety 
child of three, whose parents quenched his frequent thirst with 
cider and water. A red nose from chronic passive hyperemia, 
due to a feeble heart, may occur in quite young children. 

The main cause for both sexes is disorder of the alimentary 
canal, chiefly associated with the range of symptoms included 
under dyspepsia; flushing after meals, constipation, and 
lithemia being among the commonest symptoms. In women, 
also, uterine disorder is a common cause, and even when there 
is no apparent uterine trouble, the eruption is generally worse 
just before a period. A feeble circulation and exposure to in- 
clement weather, or vital depression from illness, overwork, 
anxiety, etc., strongly predispose to the eruption, or aggravate 
it, if already present. Excess in alcohol in any form especially 
favors the development of the worst forms of the disease, and 
occasionally it appears to be due to local irritants, e. g., ill- 
advised cosmetics. 

Redness, thickening, and dilated venules may also be pro- 
duced in the nose, by the chronic pustular folliculitis within the 
nostrils to which some persons are liable. 

Rhinophyma occurs almost exclusively in men, but a case was 
shown at Mr. Hutchinson's museum in a woman, get. fifty-one. 
On the tip of her nose was a tomato-sized tumor only a little 
redder than normal, smaller growths on the alae nasi, and a flat 
florin-sized one on the chin, which had commenced twenty-five 
years before, while the nasal tumors had been present only ten 
* " Le Rachitisme," p. 123 (Paris, 1892), 



ACNE ROSACEA. 1151 

years. She had suffered from dyspepsia and flushing from the 
age of eighteen, but not from pustules; she was not addicted to 
alcohol. 

Pathology. — The first change appears to be congestion, begin- 
ning in the deeper vascular layer of the corium, but afterwards 
affecting all the vessels. This congestion, generally of reflex 
origin, but sometimes from a direct irritation, is followed by 
secondary seborrhea or inflammation in the sebaceous glands, 
and perhaps other parts of the skin, producing sooner or later 
papules, pustules, or nodules, and ultimately paretic changes 
occur in the walls of the vessels, which become permanently 
dilated, thickened, and perhaps even new vessels form. In the 
hypertrophic cases there is a formation of new connective tis- 
sue round the vessels, and the rhinophymata are mainly com- 
posed of enlarged sebaceous glands and connective tissue. This 
makes the disease primarily a vaso-motor reflex neurosis, while 
Schwimmer regarded it as a tropho-neurosis, on what appear 
to me to be inadequate grounds. Unna claims it to be another 
manifestation of the seborrheic process, a sequence of seborrheic 
eczema, although he admits that it differs from all other sebor- 
rheic processes. The nodules he ascribes to a special follic- 
ulitis, but his statements on the question are not convincing 
to me. 

Other theories have also been advanced, but do not fit the 
facts so well as the above. 

Anatomy. — G. Simon examined a nodule from a drunkard's nose, and 
found that it consisted of connective tissue, traversed by enlarged vessels. 
The sebaceous glands were also enlarged, and filled with hardened 
sebum. He regarded the other changes as secondary to those of the 
sebaceous glands. Piffard examined a tumor weighing an ounce, and 
found that it consisted of connective tissue, with thickening of the rete 
and enlargement of the papillae. The sebaceous glands were degenerated 
where they were pressed upon by fibrous tissue, but not otherwise 
changed. On the other hand, Hans v. Hebra found in hypertrophic acne 
a connective tissue new growth with numerous dilated and new vessels, 
the sebaceous glands numerous and enlarged, due, he considered, to the 
fibrous tissue cutting off some of the acini from the rest of the gland; and 
as secretion continued in these detached portions, the glands multiplied, 
while the retained sebum irritated the surrounding tissue to fresh growth. 
Rokitansky also found a large tumor to be entirely composed of fibrous 
tissue, containing large vessels, with no sebaceous changes. In my own 
case, the sebaceous glands were very abundant and conspicuous. 



1 152 DISEASES OF THE SKIN. 

Diagnosis. — The age of the patient at the onset of the disease, 
the history of flushing after meals, alcohol, or exposure to 
changes of temperature, etc., the obvious vascular dilatation, 
the special distribution in the middle two-thirds of the face, and 
the symmetry * of the eruption, the papules and pustules fol- 
lowing, not preceding the other symptoms, and the slow devel- 
opment of the disease, are its most diagnostic features, and dis- 
tinguish it from A. vulgaris, in which there are comedones and 
no general redness, while the eruption is chiefly on the sides of 
the face, and often on the trunk as well. 

Erythematous eczema is much more acute in onset and develop- 
ment, is not limited to the middle of the face, desquamates from 
the beginning, and is associated with irritation; nor are there the 
pustules of A. rosacea. 

In erythematous lupus the surface is generally scaly, often with 
scarring, more projecting than the hyperemic stage of acne, 
more defined and raised at the age, and lacks the nodules of the 
hypertrophic stage of rosacea. At the same time, in the early 
stage of acne, the sebaceous accumulation in the follicles may 
lead to mistakes, if all the features are not taken into consid- 
eration. 

Some cases of superficial nodular syphilids are very like A. 
rosacea, but being a tertiary condition, the syphilid is not sym- 
metrical, very likely to ulcerate, more rapid in development, and 
the border more defined; it varies less with the surrounding con- 
ditions, and lacks the telangiectases of A. rosacea, in which also 
there are no ulcers, crusts, or cicatrices. Evidence of past 
syphilitic lesions can generally be found elsewhere in the case 
of a nodular syphilid. The possibility of mixed conditions must, 
however, always be borne in mind in a chronic disease like A. 
rosacea, as of course it does not exempt from other eruptions. 
Thus I have seen iodid acne associated — a puzzling combination 
suggestive of syphilis. The localization was a guide to the 
rosacea, and the free suppuration to the iodic eruption. 

Prognosis. — Considerable relief can generally be afforded, and 
often complete removal of the eruption can be effected, with care 

* Iti an express-train engine-driver this law of symmetry was curiously 
broken through by his occupation. The left side of the face, which was 
always on the outer side as he stood on the engine, was badly affected, 
while the right protected side was free from eruption. 



ACNE ROSACEA. 1153 

and perseverance on the part both of patient and physician, in 
cases of the first and second degree, but the return of the 
eruption can only be avoided by the removal of the cause and 
avoidance of the known conditions which favor the disease. 
Surgical procedures may also do much for the hypertrophic 
cases. 

Treatment. — The line of internal treatment is determined by 
the general health. Careful attention to the digestion is of pri- 
mary importance in most cases; the diet should be regulated; 
alcohol is generally better avoided entirely, unless in very small 
quantities in atonic dyspepsia at the beginning of a meal; beer, 
stout, and effervescing and acid wines are generally particularly 
injurious; fermentable articles of diet should be avoided, such 
as sweets, pastry, rich gravies, thick soups, etc., and generally 
plainly cooked, easily digestible food should be chosen; tea and 
coffee are often, but not necessarily injurious, and those kinds 
of cocoa in which the superfluous fat is removed are preferable 
to the cruder or starchy kinds. Cold winds, or any great alter- 
nations of temperature, should also be guarded against. Medici- 
nally, alkalies, or where there is irritative dyspepsia, bismuth 
and bitter tonics, e. g., gentian, cascarilla, nux vomica (Mix- 
tures, F. 8-12), etc., are the kinds of drugs suitable to most 
cases, but in atony of the stomach the mineral acids often agree 
better; if there is a gouty tendency, potash is preferable to soda, 
and Bulkley speaks highly of acetate of potash in dyspepsia with 
acidity. Constipation must always be combated by such treat- 
ment as is recommended under eczema for that condition. In 
women, the uterine and catamenial functions should be inquired 
into; but not infrequently these troubles are secondary to defects 
in the general health, and subside when these are rectified. On 
the other hand, the dyspepsia, debility, etc., may be due to the 
exhausting effects of leucorrhea, menorrhagia, etc. Direct 
remedies are seldom of much use; arsenic is seldom beneficial, 
and generally injurious, except in drop doses for drunkard's 
catarrh of the stomach; ergot is said sometimes to be of service 
in contracting the dilated vessels, but as these are veins this is 
very doubtful. Unna claims that ichthyol, in doses of three to 
five minims, made into a pill and taken three times a day, does 
all that is required. It certainly suits some cases, but aggravates 
others, especially where dyspeptic symptoms are prominent, and, 
73 



1 1 54 DISEASES OF THE SKIN, 

in my opinion, a carefully planned treatment founded on general 
principles is the most reliable. In rosacea acuminata, however, 
ichthyol is most efficacious. 

Local treatment is of great service in this as well as the other 
form of acne. The papules and pustules may be treated with 
sulphur compounds, as in A. vulgaris, the unguent, sulph. hypo- 
chloridi (Ointments, F. 19) being one of the best; a five to ten 
per cent, ichthyol ointment is a favorite with many; or resorcin 
oss; cremor frigid, or vaselin gj may be used, and has the ad- 
vantage of not being a disagreeable application; or in obstinate 
cases Vleminckx's solution, 1 part to 4 or 5 of water (Parasiti- 
cides, F. 11), applied at night, and in the daytime more sooth- 
ing applications, such as calamin and bismuth lotion (Lotions, 
F. 41, 42). For the permanently dilated and varicose vessels 
the best plan of all, and leaving least mark, is electrolysis, in 
the same way as that for the removal of superfluous hairs, 
but a weaker current must be used — three to five • cells 
is sufficient. Of course the cause must be removed or other 
vessels will enlarge. This has in my hands entirely super- 
seded the older plan of multiple scarification, splitting up 
the larger vessels, or superficial cauterization with Paquelin's 
cauteries. Multiple scarification is, however, very valuable in 
the hypertrophic forms without actual tumors, also in the ex- 
ceptional cases where innumerable pustules are aggregated 
together. Europhen or similar microbicides should be rubbed 
into the incisions. For the red nose due to seborrhea nasi the 
treatment has been described under that for seborrhea. A modi- 
fication of scarification is proposed by Lassar for red noses. 
Forty gilt needle-points are fixed in a disc, and this connected 
with an electromotor similar to that used by dentists for stop- 
ping teeth. By this means hundreds of pricks are made in the 
skin in a short time with abundant hemorrhage, which can be 
stopped at will by pressure. It is chiefly useful where there is 
redness without the presence of visibly dilated vessels, which 
could be dealt with by electrolysis. 

Nodulated noses may be trimmed with a knife down to their 
normal size; cicatrization takes place readily, and the result is 
usually very satisfactory. Large tumors must be removed by 
the usual surgical methods. Veiel recommends cataplasms and 
painting once daily, with a two per cent, alcoholic solution of 






ACNE VARIOLIFORMIS. 1155 

pyrogallic acid for the nodulo-pustular thickened noses, or the 
application of emplastrum cinereum. Few English patients will 
submit to these applications, as the method is tedious and in- 
creases the disfigurement for the time being. 



ACNE VARIOLIFORMIS.* 

Synonyms. — Acne frontalis ; Acne atrophica (Bulkley and Bazin) ; 
Acne necrotica (C. Boeck); Acne rodens (Vidal and Leloir). 

Definition. — A pustular folliculitis, which predominates on the 
upper part of the face and on the scalp, and leaves scars like 
those of smallpox. 

The term " acne varioliforme " was originally given by Bazin 
to molluscum contagiosum, but acne varioliformis was adopted 
by Hebra and his followers for the somewhat rare eruption 
(1 1-2 per 1000) under consideration, in which sense it is now 
always employed. 

Symptoms. — It occurs usually in the center of the forehead, 
on the sides of the temples, at the margin of the hairy scalp, 
and on the scalp itself, both at the temples and the vertex; it 
is seen less frequently on the sides and other parts of the face 
and neck. In two of my cases it was also on the chest, and 
in one on the scrotum and on the back. The face, scalp, or 
both were affected as well in all. In a case of Isaac's shown 
at the Berlin Dermatological Society, the lesions were on the 
extremities only, but probably, like Bronson's case, it was really 
a folliclis. 

It consists of indolent, red, flat papules or nodules, about the 

size of the hemp seed, rather firm at first, but later suppurating 

at the apex, and drying up into small, flat, closely adherent 

scabs, which press into the skin, and when they fall off, leave a 

pit about one-eighth of an inch in diameter (occasionally much 

larger), at first stained dark red, passing into a brownish hue, 

and subsequently blanching and looking like a smallpox scar; 

hence the name varioliformis. They are massed together, but 

* Literature. — Author's Atlas, Plate LXXXVL, illustrating the disease 
on the scalp, face, and trunk. Neumann's Atlas, Plate III., shows an 
eruption disseminated over the whole face, but this is unusual. It is the 
same case as that published by Pick, which Dubreuilh identified as 
hidradenitis. Vide Acne Agminata. 



1156 DISEASES OF THE SKIN. 

without definite grouping, in the temples and hair margin of 
the forehead, while in other parts of the head and trunk they 
are irregularly disseminated. 

The earliest lesion is a convex papule, with minute pin's- 
point, hard center, apparently confined epithelium. When a 
little larger a ring of pus or sero-pus, and outside this a narrow 
red ring surrounds the horny-looking center, which has also 
pari passu enlarged until it assumes the appearance of a distinct 
scab. The eruption is painless, but itches slightly at times. It 
is very chronic, and tends to recur sooner or later, some of my 
cases having a history of ten years' intermittent duration, and 
two nearly thirty years. 

A milder form occurs in which the lesions are more superficial, 
from a pin's head to a millet seed in size, and the apex has a 
small scab, which, when removed, only leaves an excoriation. 
They may be very numerous over the head and face, but being 
superficial leave no scars, or only a small transitory one. The 
larger, more characteristic lesions are sometimes sparsely pres- 
ent as well. Oily seborrhea invariably precedes and accom- 
panies the disease, and according to Sabouraud there can be no 
acne varioliformis without an oily seborrheic foundation. 

Etiology. — It occurs both in men and women generally over 
thirty, but I have seen it under twenty-five years of age, and one 
case was said to date from vaccination in infancy, but this is 
improbable. Its predisposing cause, if Sabouraud is correct, is 
oily seborrhea. In eighteen cases which I have examined, eight 
were males, ten females; three had had syphilis, three gonorrhea, 
and twelve neither. Their ages varied from twenty-one to 
seventy. 

Fordyce suggests on good grounds that, as it is an affection 
chiefly of the poor, and its localization is on the forehead and 
scalp, where pressure from dirty head coverings would occur, 
a microbic infection is probable. How that produces it is now 
to be detailed. 

Pathology. — The first step appears to be a minute horny plug, 
which sets up inflammation and necrotic destruction, and separa- 
tion of the portion of the skin affected. 

Anatomy. — Microscopic examination of excised papules has been made 
by Touton, Fordyce, and Sabouraud. Fordyce found that the papules in 
the early stage were in the derma round the hair follicles; Touton also 



ACNE VARIOLIFORMIS. 1157 

found them in the middle and upper part of the corium. The first 
changes were dense round-celled infiltration round the hair follicles, 
generally above the sebaceous glands, which might or might not become 
involved. The infiltration extended laterally and upward, involving the 
papillary and subpapillary layers, the walls of the follicle, and the 
epidermis; these finally became disintegrated and destroyed, though the 
lower part of the follicle and the sebaceous glands often escaped complete 
destruction. 

Fordyce * found enormous numbers of staphylococci in the 
lymph vessels and free in the tissues. He thought that their 
number, distribution, and appearance before the lesion had in- 
volved the epidermis rendered their etiological relationship very 
probable. Touton f found staphylococcus, tetracoccus, and a 
short thick bacillus chiefly in the upper layers of the crust and 
round the orifices of the hair follicles, and he therefore regards 
their presence as secondary. In Fordyce's second case, a more 
advanced lesion, he found no organisms. 

Dubreuilh J disputes its pilo-sebaceous origin; the follicles, he 
says, traverse the lesion, but are not central, and the inflamma- 
tion extends into the infundibulum, but not beyond it. The 
suppuration when present is due to the elimination of the ne- 
crotic focus, which is cone-shaped, with the base at the surface. 

If, however, Sabouraud's § lucid description is correct, all dif- 
culties and doubts vanish. He says the first step is the invasion 
of the follicle by the seborrheic micro-bacillus, and the irrita- 
tion of the epidermis by their presence in the upper third of the 
follicle, which produces encystment into a cocoon with concen- 
tric horny cells. Thus, then, is the central horny plug produced; 
as a consequence, there is progressive atrophy of the hair, 
hypertrophy of the sebaceous gland, and an oily seborrhea. Be- 
fore acne varioliformis can be produced this lesion must be 
invaded by the staphylococcus aureus, which gets in by the side 
of the horny plug, and abundant leukocytes are effused all 
round and set up an inflammatory edema which clinically is the 
sero-pustular circle (serous, Sabouraud says). The leukocytes 

* Fordyce, Amer. Jour. Cut. and Ge7i.-Ur. Dis., vol. xii. (1894), p. 152. 

\ Abs. of Touton's paper, Brit. Jour. Derm., vol. iv. (1892), p. 265. 

:}: Dubreuilh, Archives cliniques de Bordeaux, 1894. Resume, Annates 
de Derm, et de Syfth., vol. v. (1894), p. 956. 

§ " L'Acne Necrotique," Annates de Derm., vol. x. (1899), P- 841, illus- 
trated; and " Les Maladies Seborrheiques," p. 86. (Masson et Cie., 1902). 



1158 DISEASES OF THE SKIN. 

infiltrate the connective tissue till they produce a slough, which 
is separated in due course. 

This makes it all so beautifully clear that it ought to be true. 
It is strange, however, that, while the conjunction of two such 
very common organisms is all that is required, yet the disease 
should be so rare, and that, unlike acne vulgaris, it is very rare 
amongst the well-to-do. 

Diagnosis. — The characteristic features of this eruption are 
that the lesion is flat with a necrotic, deep-seated scab in the 
center which leaves varioliform scars, occurs on the temples 
and forehead, and goes back into the hairy scalp. The last 
point will distinguish it from all other forms of acne, which do 
not affect the scalp. 

It has been confused with acne agmiiiata, and its diagnosis is 
given under that affection. 

It is somewhat like the corymbose papular syphilid, but this is 
always a secondary eruption, and widely spread over the rest 
of the body. A syphilid like A. varioliformis belongs to the late 
tertiary period, and is rarely seen anywhere except on the head 
and neck. 

Prognosis. — It is almost sure to recur sooner or later. 

Treatment. — In my experience the majority of cases improve 
under iodid of potassium, but some do better with iron; from 
fifteen to twenty-five minims of the perchlorid should be given 
three times a day. Improvement soon results, and I have cured 
/cases with this alone, using no local treatment. Prolonged 
treatment is required for complete removal of the eruption, and 
if evidence of a syphilitic taint be obtained a mild mercurial 
course, alternating with the iodid, should be continued, for at 
least a year. In one case, after seven years' duration, the per- 
sistent use of iodid of potassium and iron apparently produced 
a cure, the disease not having recurred during the last ten years. 
Locally, mild mercurial applications, such as the diluted nitrate 
or ammoniated mercury ointment, should be frequently smeared 
on, and this is enough to remove the lesions actually present. 
Probably, if the horny center of the early papule were removed 
and iodoform or other antiseptic applied, abortion of the lesion 
would be induced, and so the scar avoided. Most of the lesions 
are in an advanced stage before the patient applies for relief. 
If, however, Sabouraud's views are accepted, then obviously the 



ACNE VARIOLIFORMIS. 1159 

seborrhea is the condition to treat in order to avoid recurrences, 
and internal medicines will be superfluous. (Vide Seborrhea.) 

Acne Scrofulosorum is a rare affection which occurs chiefly 
in young children, though Bazin is said to have described a 
case in a boy of seventeen years. Of this I was unaware when 
I called attention to the affection, relating three cases at the 
International Dermatological Congress in Vienna in 1892.* 
Since then an article has been written by Colcott Fox and 
several cases have been exhibited at the London and Paris 
Dermatological Societies. The most characteristic seats are the 
buttocks and backs of the thighs, but any part of the lower 
extremities may be attacked, and the extensor aspect, less often 
the flexor aspect, of the arms and forearms; and the sides of the 
face in some cases. The trunk, in this form, is seldom in- 
volved f higher than the loins. The eruption consists of pin's- 
head to hemp-seed-sized lesions for the most part, but a few- 
attain to the size of a small pea. They consist of small pustules 
on a highly inflamed, often livid red base, but the lesion is only 
moderately firm, not so hard as ordinary acne and evidently 
seated at the hair follicle. They do not itch. 

The eruption comes out in crops a few at a time, the older 
ones undergoing absorption and leaving purplish stains, but 
they seldom leave scars, as they are quite superficial for the 
most part, but occasionally they extend both laterally arid verti- 
cally and produce deeper ulcerating lesions, as in Galloway's and 
Hallopeau's cases. On the other hand, a milder form than usual 
may occur, as in one of my cases, a boy, set. four, in whom the 
eruption was a sequela of measles and consisted of pin's-point 
to pin's-head papules, and only some of the larger ones pre- 
sented a minute vesiculo-pustular cap. The smaller ones had 
horny plugs in the center. 

Fox and Galloway J examined lesions microscopically, and 
found no evidence of tubercular structure and no bacilli in 
guinea-pig and rabbit inoculations. The inference is that it is 
certainly not directly tuberculous, but may be due either to 

* " Acne Scrofulosa," Rep. of Inter. Cong. Derm. IVz'en (1893), p. 510. 

\ Brit. Jour. Derm., vol. vii. (1895), p. 341, with colored plates; also 
vol. vii. (1894), p. 294, Jamieson's two cases of impetigo varioliformis, 
which he admits are acne scrosulosorum. 

% Brit. Jour. Derm., vol. ix. (1897), p. 273. 



n6o DISEASES OF THE SKIN. 

tuberculous toxin or to some other toxin favored by the 
tuberculous predisposition. 

In almost all of the cases there is distinct evidence of tu- 
berculous manifestations in the shape of enlarged glands, ul- 
ceration of the cornea, etc., together with a family history of 
phthisis, and the patients are nearly all infants or young chil- 
dren, but a few have been adolescents. A sub-variety of this 
condition is seen in the more or less abundant acne pustules 
which appear chiefly on the trunk in some cases of lichen scrofu- 
losorum. Epithelial occlusion of the gland orifices is probably 
the proximate cause in these cases, and perhaps in the others 
also. 

The treatment is to administer cod-liver oil in full doses with 
iron and rub in a resorcin or sulphur ointment of about ten 
grains to the ounce. The eruption responds favorably to these 
measures, in a short time. 

Acne Keratosa.* I have differentiated under this title a rare 
form of acne, of which I have met with four cases in women, and 
a fifth case, in a man, of a somewhat different character. 

As the case usually presents itself to the observer there are 
finger-nail-sized, well-defined, excoriated patches covered with 
hard blood-stained crusts situated on the cheeks and chin, espe- 
cially near the angles of the mouth. There are also numerous 
scars of old lesions of the same size and shape as the earlier 
ones, white to red in color according to their duration. The 
lesions, as a whole, are symmetrical, taking all the stages to- 
gether, but they come out singly or in very small numbers at 
irregular intervals, and are very persistent. They commence 
as a red, firm, tender lump, on which a pustule usually forms 
and dries into a scab, or the epidermis is detached by the under- 
lying lymph. The patient removes the scab from an irresistible 
desire to squeeze or pick out soft or horny, conical-like plugs 
about a twelfth of an inch long, which are imbedded in the 
skin, and give rise to great irritation, and sometimes pain and 
tenderness, until they are removed; sometimes there is only one 
plug, but there may be several. When they have been ex- 
tracted the sore heals slowly, the whole process taking from 
weeks to months, and with a tendency to recur in the same 
* Brit. Jour, Derm., vol. xi. (1899), p. 1. 



ACNE VARIOLIFORMIS. n6i 

place, if all the horny plugs are not out, and in some instances 
to spread slightly at the periphery. 

More frequently a fresh lesion appears near the old one, gen- 
erally followed at a varying interval by a corresponding one on 
the opposite side; thus the disease is kept up for years, in one 
case forty years, slightly controlled by treatment, but never 
cured. The horny plugs, which were examined by Jamieson and 
myself, were about the size of the end of a tin-tack, and com- 
posed of epithelial horny cells with a few prickle cells and cell 
nests. Jamieson compared them to the comedo, and thought 
they were derived from the sebaceous glands, but it appears to 
me that they are from the hair follicle itself. 

The etiological factors are rather scanty, one case was appar- 
ently traceable to the direct effect of exposure to severe cold. 
The first and the two last cases had probably developed from 
acne vulgaris. In all of them digestive disturbances were pres- 
ent, and in three they were very prominent. All four cases 
were women in comfortable circumstances; one was probably 
a cocain-taker. 

The cases differ from the excoriated acne of Brocq,* which is 
seen sometimes in young girls, and is due, he thinks, entirely 
to a morbid or hysterical impulse to pick the spots apart from 
irritation. I think, however, that these cases really itch severely. 
In one of his cases also the eyebrows were picked out — 
" Trichoptilimania," as Hallopeau calls it. These excoriations 
are much smaller than in the disease just described, and there 
are no horny plugs to remove. I regard it as an acne vulgaris 
with pruritus, and not as a merely hysterical manifestation. My 
A. keratosa cases varied from thirty-one to sixty-four years of 
age, and were all very rebellious to treatment, and had lasted 
for years. The measures that gave most relief were those di- 
rected to improving digestion, and locally mild antiseptics of 
the iodoform and boric acid class. I think Kaposi's f Acne 
urticata is a somewhat similar affection to the one I am de- 
scribing, only he has not described the " horny plugs " which 
characterize A. keratosa, and he speaks of it as attacking the 
limbs. Like mine, his cases were of long duration — fifteen or 

* " L'Acne excoriee des jeunes filles," Brocq (Paris: Charles Schlaeher, 
1898). 
f Kaposi, Amer. Edit., p. 372. 



n62 DISEASES OF THE SKIN. 

twenty years, he said. As in my cases, the patients are im- 
pelled to scratch or pierce them, and then squeeze them to get 
temporary relief by getting blood or serum out of them. They 
begin as pale red, wheal-like, hard elevations from a bean to a 
shilling in size. 

My fifth case in a male is as follows: 

Nathan, J., set. twenty-five, a tailor, first seen in January, 1885, had 
suffered from an eruption off and on for two years. It was situated about 
the nose, cheeks, and forehead, the sides and front of the neck, the 
extensor aspect of the forearm, wrists, hands, and fingers, on the side of 
the forefinger, on the front and back of the thighs, but there were no 
lesions below the knees. The distribution was evidently where the hair 
follicles were most abundant, but also in a few parts where the hair 
follicles were doubtfully present; three or four lesions at a time came 
out in various places, but were not grouped. 

The eruption consisted of indolent, inflammatory, very firm, conical 
papules, from one-sixteenth to a quarter of an inch in diameter, in the cen- 
ter of which was a nail-like plug of ordinary epithelium, which left rather 
a deep hole when picked out; some of these suppurated, forming a small 
pustule on a conical red base, which only took a day or two to form, but 
after the pustule was ruptured the inflamed base remained unchanged for 
weeks. When first formed it was only a pin's-head-sized, slightly red 
papule with a small horny plug, but both the plug and base increased in 
diameter, and it was not until the whole was a quarter of an inch in size 
that suppuration took place, and then only in certain lesions. Each 
lesion was very slow in its course, but ultimately the induration was 
absorbed, leaving scarring and pigmentation in some places. Subse- 
quently some of the lesions on the face enlarged to half an inch in 
diameter, forming much-inflamed, indurated, raised nodules with a 
flatfish top, which softened in the center, almost like a carbuncle, but the 
central mass was slow in separating. The general health was good; the 
patient was badly marked with smallpox, but there was no evidence of 
syphilis, and specific, and, indeed, all other treatment, had no effect on 
the development or number of the lesions. Some years later I traced him 
out, and found that he had completely recovered, but not from any special 
treatment. When first shown to the Dermatological Society, no one except 
Hutchinson had seen a similar case, which was equally obstinate. Elliot's 
case was probably one of this kind. 

The main differences are the much wider distribution and, 
for a long period, the formation of lesions round a single plug 
instead of multiple horny nail-like plugs, and the lesions being 
more distinctly raised and the plugs obvious, but these differ- 
ences seem scarcely sufficient to justify one in considering the 
disease to be distinct from that of the ladies', and it is probably 
onlv a variant of it. 



ACNE VARIOLIFORMIS. 1163 

The pathology would appear to be that horny cells, derived 
in all probability from the lining of the hair follicle, are aggre- 
gated into a horny peg, which by its presence in the mouth of 
the follicle acts as an irritant, and an inflammation round it is 
set up, just as it is round a comedo, but the whole process is 
much more indolent, and the plugs are multiple instead of single. 

Acne sebacee cornee is a French synonym for lichen pilaris 
or spinulosus. Cases have recently been described by Ten- 
neson * and Hallopeau f as a new affection with horny spicules. 
Tenneson calls his acne keratique, and considers it different from 
Hallopeau's acne cornee. From their description I am unable 
to distinguish any important difference from lichen pilaris. 

Acne necrotisans et exulcerans serpiginosa nasi is the 

lengthy appellation given by Kaposi to a rare affection of which 
he has observed three cases, two men and one woman, in middle 
life. I transcribe Kaposi's own words (p. 373 of the American 
translation of his lectures): 

" It occurs as an acute eruption on the tip of the nose, in 
Avhich flabby papules, as large as a pin's head or a little larger, 
developed; these rapidly underwent purulent or necrotic de- 
generation, resulting finally in numerous deep scars. A dense 
row of new papules running the same course then developed 
at the margin, and this continued until within a few weeks or 
months; the cutaneous part of the nose was destroyed by the 
deep cicatrices. Even after scraping out the papular wall formed 
by the new eruption around the cicatricial part, relapses still 
continued, until the process stopped at the level of the bony part 
of the nose. The curetted tissue proved to be vascular, flabby, 
granulation masses with numerous giant cells." J 

There was great resemblance to syphilis pustulosa, except that 
the papules were very flabby and vascular, while their original 
size and prominence, their rapid development and destruction, 
excluded lupus vulgaris. 

A very similar condition is recorded by Leslie Roberts § under 

*Jour. Czit. and Gen.-Ur. Dz's., vol. xii. (1894), p. 362. 

f Ann. de Derm, et de Syfih., vol. vi. (1895), pp. 285, 305. and 1141. 

% " Ueber einige ungewohnlicbe Formen von Acne," Kaposi, Archiv f. 
Derm. it. Syph.. vol. xxvi (1894), p. 82, with colored plate, repeated in 
Plate IX. of his Hand Atlas. 

§ Brit. Jour. Derm., vol. ix. (1897), p. 179. 



1 1 64 DISEASES OF THE SKIN. 

folliculitis necrotica, and Wilhelm showed a case at the Vienna 
Dermatological Society. A similar development of vascular 
granulation tissue at the follicle followed by necrosis occurred 
in Lukasiewicz's case * of folliculitis exulcerans, also from Ka- 
posi's clinic, but this was on the nates and limbs of an anemic 
girl during nearly three years. They occurred in large numbers 
in patches which extended peripherally from a crown to palm 
size. Cure was effected by the repeated application of the 
thermo-cautery. This is perhaps a similar process to the de- 
pilating folliculitis of the limbs described by Arnozan in middle- 
aged and elderly people. 

Kaposi gave the name of Acne telangiectodes f to a case 
with non-suppurating spongy vascular papules throughout the 
face, mingled with ordinary acne. Curetting cured it. It is 
probably Acne agminata. 

ACNE AGMINATA. t 

Synonyms. — Disseminated follicular lupus (Tilbury Fox); Acne 
telangiectodes (Kaposi); Acnitis (Barthelemy). 

This is a still rarer affection than folliclis, and was first de- 
scribed by Tilbury Fox in 1878, from three cases which he 
regarded as a form of lupus, as will presently be shown. I think 
it is identical with Barthelemy's acnitis, but not with folliclis. 
Cases have been shown at the London Dermatological Society 
by Perry (2), Galloway and myself (2). 

Symptoms. — The eruption is for the most part confined to the 
face, but the limbs may be affected. The most striking feature 
in a well-marked case is the tendency of the lesions to group 
about the chin, cheeks below the orbit, the brows, the temples, 
the upper lip, and the lower eyelids, while there are also scat- 

* Reports in Annates de Derm, et de Sypn., vol. x. (1898), p. 1065. 

\ Loc. ci't. of Archiv, and Plates VII. and VIII. of Kaposi's Hand Atlas. 

% Literature. — Tilbury Fox, Lancet, July 13 and 20, 1878, pp. 35 and 75. 
Barthelemy, Annates de Derm., vol ii. (1891), p. 1, with good colored 
plate, " De l'Acnitis "; as " Acne nodulaire," he had previously described 
a case in the Annates of 1881. Kaposi, Hand Atlas, Plate VII., Acne 
telangiectodes, an extreme case. Pick, " Acne Frontalis seu Varioli- 
formis," Archiv f. Derm. it. Syph., vol. xxi. (1889), p. 551, colored plate 
of the face, but it also attacked the backs of the hands and the forearms. 



ACNE AGMINATA. 1165 

tered lesions on the sides of the face and other parts, and a very 
few on the nose. In one of my cases it was limited to the eye- 
lids, chiefly the lower. The individual lesions vary from a pin's 
head to a hemp seed, as a rule, occasionally a little larger. They 
are mostly of a uniform, dull brownish-red tint, but some of 
them have a yellow central point, with or without a comedo; 
in one of my cases there were many with comedones in them, 
but the great bulk were not connected with the sebaceous 
glands. A large proportion contained pus even when they 
appeared to be solid, but in other cases they have been firmer, 
and nothing but blood came out when they were pressed. In 
a few instances two or three lesions had coalesced into an oblong 
nodular patch which had the lupoid aspect which struck Tilbury 
Fox so much. The general aspect is that of an acne for the 
large discrete lesions, but the smaller ones are less inflammatory 
and have a glistening waxy aspect; the grouping also is a dis- 
tinguishing feature. 

In some cases the spots involute with or without suppura- 
tion, and leave a small brownish pigmented scar, but as a whole 
the eruption is very indolent and persistent, quite unaffected 
by the ordinary acne treatment, and scarcely changes at all ex- 
cept as regards vascularity. Perry's case, however, cleared off 
rather rapidly when involution once set in, and not, I believe, as 
the result of treatment. 

In neither Fox's, Perry's, nor Galloway's cases were there 
any lesions in other parts of the body, but in two of my cases 
there were a few scattered lesions on the forearms; they were 
pale red, hemp-seed-sized, firm, and more deeply seated than 
those on the face, and did not suppurate. There were a few 
papules on the neck, and one on the rim of each ear. 

The course appeared to be first the development of a small 
shotlike lesion under the skin, to be felt but not seen, then slight 
enlargement, implication, and reddening of the skin, and ulti- 
mately it projected above it as already described. There was, 
however, very little tendency to break down spontaneously and 
discharge, and form a scab adherent until healing took place, nor 
could I trace that each lesion completed its course in two to 
six weeks, as Barthelemy describes in acnitis, but if the lesion 
disappeared spontaneously or by treatment, a pigmented de- 
pression was left. In other respects the disease closely cor- 



1 1 66 DISEASES OF THE SKIN. 

responded with acnitis, and the distribution was very like Fig. i 
of his 1 89 1 paper, only the lesions were more distinctly in 
crowded groups. If I am right in considering that the resem- 
blances outweigh the differences, and identifying this disease 
with acnitis, I think, as far as my experience goes, Barthelemy 
is right in keeping it separate from folliclis. For the diagnosis 
from this, see Folliclis. In two of my cases there was no evi- 




Fig. 70. — Acne agminata. 

dence of tuberculosis either in the patient or his family, but in 
a third the family history was very bad. 

Pathology. — Tilbury Fox * regarded the dense cell infiltration 
throughout the corium permeating between the fibers, very 
thick in the papillary layer and round the hair follicle, and partly 
in the sebaceous glands, as a proof of its lupus character. Bar- 

* The microscopic drawing illustrating his paper was taken from sections 
made by myself from a papule excised from above the upper lip, and 
at the time I regarded the lesion as of an adenoid structure. 



F0LL1CLIS. 



1167 



thelemy considers the affection the result of auto-intoxication 
from intestinal absorption, and thinks dilatation of the stomach 
is a frequent concomitant. 

Darier found in one of Barthelemy's cases epithelioid and 
giant cells localized round the pilo-sebaceous follicles. Bar- 
thelemy himself found all the constituent elements of the skin 
involved, and could not determine any point of departure from 
any one of them. The fact that the mucous membrane of the 
mouth may be involved negatives the sweat coils as the only 
point of departure. 

Galloway examined a nodule from the eyelid of one of my 
cases, and found abundant giant cells, and a general aspect of 
tubercular structure, but no tubercle bacilli were discovered. 

Pernet * examined a nodule from the cheek of the case of 
Fig. 70, and found that the primary and chief change occurred 
about the sweat coils, which were disorganized by an inflam- 
matory leukocytic infiltration. Some of the hair follicles were 
partially involved, and there was perivascular infiltration. No 
tubercle bacilli were found. 

The treatment is given under " Folliclis." 

FOLLICLIS (Barthelemy).t 

Synonyms. — Lupus Erythemateux dissemine (Boeck); Follicu- 
lites disseminees symetriques des parties glabres a tendance 
cicatricielle (Brocq) ; Acne varioliformis of the extremities 
(Bronson) ; Folliculitis exulcerans (Lukasiewicz) ; Hydra- 
denitis destruens suppurativa (Pollitzer) ; Idrosadenite 
suppurative disseminee (Dubreuilh) ; Scrofulides nodulaires 
disseminees (Dubreuilh's Handbook) ; Spiradenitis suppura- 
tiva disseminata (L^nna) ; Tuberculides (Darier) ; Granulome 
innomine (Tenneson); Folliculites tuberculeuses (Kracht); 
Tuberculides acneiformes et necrotiques (Hallopeau, Bal- 
zer, and Leroy); Toxi-tuberculides papulo-necrotiques 
(Hallopeau's latest). 

Hutchinson was the first, as Boeck has shown, to differ- 
entiate this rare affection, and point out its frequent association 

* Brit. Jour. Derm., vol. xiv. (1902), p. 131. The clinical account is at 
p. 18 of the same volume. 

f Illustrated by Barthelemy, " De l'Acnitis," Annates de Derm., vol. 



n68 DISEASES OF THE SKIN, 

with lupus erythematosus. Then came Boeck, Brocq, and Bar- 
thelemy, and the rest, each describing independently and 
christening the supposed new affection according to his view 
of its pathology. 

I have chosen the name " folliclis," given by Barthelemy, on 
account of its brevity, and as merely a clinical label which does 
not assume much as to the nature of the disease. The other 
names are too long for ordinary use, and too dependent on 
doubtful pathological theories. 

It is a disputed point as to whether folliclis and acnitis (vide 
Acne Agminata) are different affections or only phases of the 
same disease, Barthelemy holding that they are separate, while 
most of his French colleagues consider them to be identical. 
Provisionally I keep them apart in the description, as folliclis 
more often occurs without acnitis than with it. The eruption 
attacks the limbs, especially the forearms and legs, hands and 
feet, the head and face being quite exempt except the ears, and 
the trunk being free in most cases, and is rarely much affected. 
The lesions are discrete and never grouped, says Barthelemy, 
but rlallopeau and others say they may form extensive but 
irregular patches, and while the back of the hands and sides 
of the fingers are frequently, and sometimes exclusively af- 
fected, the palms are seldom attacked (vide Dubreuilh's case); 
but I have seen it on the palmar side of the finger-tips. Each 
lesion is very constant in its characters, commences as a red 
point, then develops into a small papule which becomes vesicu- 
lar, and forms a white apex to the papule, which is then easily 
felt in the skin, and goes on to a small almost painless nodule 
containing pus, which may form a ring round a horny center 
and have a red areola. When it bursts very little pus escapes, 
as most of it dries into a crust, which falls after five or six 

ii. (1891). p. 1.; colored Plate I., Fig. 3, represents elbow. Hallopeau and 
Leredde, Plate XII., p. 521; a good representation about foot and ankle. 
Good photographs: Bronson, "Acne Varioliformis of Limbs," Amer. 
Jour. Cut. Dz's., vol. ix. (1891), p. 121, of forearms and back of hand, and 
microphotographsby Fordyce. Duhreuilh, " Hydrosadenites suppuratives 
disseminees." Arch, de Med. experiment ale, January t, 1893, palms. 
C. Boeck, " Die Exantheme der Tuberculosa" Arch.f. Demi., vol. xlii. 
(1897), pp. 7 and 175, gives complete history and references. " Dermatitis 
nodularis necrotica." Torok, Archiv /. Derm. u. Syph., 1901, vol. lviii., 
p. 337- 



FOLLICLIS. 1169 

days, and leaves a cicatrix, first red, then pigmented, and finally 
white, from a millet to a lentil in size, seldom larger. The ear 
rims are irregularly cicatricial, and are very liable to chilblains. 
Its course is very indolent, as a whole, but individually each 
lesion takes from four to six weeks, but sometimes it is more 
active. One of Barthelemy's cases had had it for ten years in 
crops, beginning in the lower limbs, and was never quite free, 
but was worse in summer, and it was aggravated by vapor baths. 
His forearms and legs were riddled with cicatrices. 

On the fingers, as I have seen it, the nodules are very hard 
and indolent, and form pus round a central hard point, and leave 
a small hole in the hard elevation which does not soften as it 
does elsewhere. I have also seen what was probably the same 
disease as a widespread superficial eruption, apparently sweat, 
follicular on the limbs and back, where it was abundant, but not 
much on the front of the trunk; the hands and feet were free, 
and there was one spot on the face. The patient, a male, set. 
twenty-three, had acute phthisis. Bureau also describes a super- 
ficial form which he considered pilo-sebaceous. 

Etiology. — Most cases occur in persons with a weak circula- 
tion, and the cases I have described as " acrodermatitis pustu- 
losa hiemalis " * probably belong to folliclis, but three cases by 
Barthelemy and others have been worse in the summer; never- 
theless cold is an important factor, as a rule. I have three times 
seen it on the hands only, along with lupus erythematosus, an 
association noticed by Hutchinson, Boeck, Hallopeau, etc. In 
a large proportion there has been evidence of tuberculosis in 
the patient or the family. In one of my patients the lupus ery- 
thematosus on the face was multiple and symmetrical and much 
crusted, but in many respects had the aspect of a lupus vulgaris ; 
she had enlarged glands and other evidence of tubercle. 

Pathology. — There has been as much dispute about this as 
about the clinical and nosological aspects of the affection. Sev- 
eral observers, as Pollitzer, Giovannini, Dubreuilh, Fordyce, 
Unna, etc., have laid stress on the involvement of the sweat 
glands, and considered it as hidrosadenitis, and Fordyce seems 
to have traced the process from the subcutaneous nodule up- 
wards; but Leredde and Bureau regard it as a granuloma of 

*"A Clinical Study of some Winter and Summer Eruptions," Brit. 
Jour. Derm,., vol. xii. (1900), p. 39. 

74 



1170 DISEASES OF THE SKIN. 

tuberculous origin, and consider the sweat-coil lesions as 
secondary. Darier also considers it to be a tuberculid. Le- 
redde * says giant and epithelioid cells are frequent, but not 
constant. Torok says it begins as an endophlebitis. No tu- 
bercle bacilli have been found, hence Hallopeau assumes it to 
be of toxin tuberculous origin; but though this is plausible for 
many cases, it is unproved, and the true pathology has yet to 
be demonstrated. 

Diagnosis. — The characteristic features are the succession of 
indolent, almost painless, nodules, with suppuration usually 
round a central hard core, leaving a small pigmented pit, and 
attacking the limbs chiefly, and occurring frequently in sub- 
jects tuberculous in themselves or relatives, and sometimes as- 
sociated with lupus erythematosus. The supposed distinctions- 
from acne agminata are as follows: 

In acne agminata the seat of predilection is the face, al- 
though the limbs may be affected. In folliclis the seat of pre- 
dilection is the limbs, and although it may affect other parts, 
the face and head except the ears are exempt. While acne 
agminata may group on the face, it is scattered on the limbs, 
but folliclis may be in irregular groups and sometimes very 
crowded ones. 

Acne agminata begins as a subcutaneous shotlike nodule 
(which may be shelled out if an incision is made over it), and 
works towards the surface, suppurates freely, and breaks down 
and leaves a scar, and both lesion and scar are larger than fol- 
liclis. In the latter the initial lesion is dermic, though deep 
in it where it forms a flattened papule, which becomes vesicular 
or pustular and often umbilicated, and never suppurates freely, 
and cannot be enucleated at an early stage. Folliclis lesions 
predominate on the buttocks, elbows, and knees. The process 
of each lesion and the disease as a whole is much more acute 
in acne agminata than in folliclis. The affection is not in any 
way connected with tuberculosis, either in the patient or family 
history, while it is so in folliclis. Dubreuilh and others do not 
admit all these distinctions, but think the cases merge into 
each other. 

Treatment. — Before suppuration apply a mercurial plaster, 

*" Sur tm Granulome Innomine," by Tenneson, Leredde, and Martinet, 
Annales de Derm., vol. vii. (1896), p. 913. 



LEPOTHRIX. 1 17 1 

such as the mercury and carbolic paraplast No. 255 of Beiers- 
dorf, or Vidal's red plaster; and it might also be used if there 
is induration left after the evacuation of the pus. When sup- 
puration has occurred remove the central core, if any, and 
syringe out with 1 in 40 carbolic solution or perchlorid of mer- 
cury 1 in 5000, and fill up the hole with iodoform. 

If there is tuberculosis in any overt form, cod-liver oil and 
other treatment appropriate to the constitutional condition may 
be given. In the winter cases, to which I have alluded, improv- 
ing the peripheral circulation, giving five grains of thiol in pill 
or cachet three times a day and rubbing in vasogen iodin ten 
per cent, appeared to be quite successful. In acne agminata 
Besnier found great benefit from giving salol internally, which 
corroborates Barthelemy's intestinal intoxication theory. 

C— DISEASES OF THE HAIR FOLLICLES. 

Diseases of the hair are dependent upon pathological changes 
in the follicle, similar to those of other parts of the skin. They 
comprise "inflammation" (sycosis or folliculitis); "trophic" 
changes, leading to " overgrowth " (hirsuties), or to " atrophy," 
producing loss of elasticity (fragilitas, trichorrhexis nodosa, 
moniliform hair, etc.); to "color" defects (canities, etc.); or if 
the damage is so severe as to lead to " falling out " of the hair 
(alopecia in various forms). Then, as pathological accidents, 
so to speak, there are " concretions " on the hair (lepothrix, 
piedra), and " vegetable parasites " (favus, tinea tricophytina). 
These last are treated of in the section on Hyphomycetic 
Diseases. 

CONCRETIONS ON THE HAIR. 

LEPOTHRIX. 

Synonyms. — Trichomycosis nodosa (Patteson); Trichomycosis 
palmellina (Pick). 

Deriv. — \enis, scale, and Opi^, the hair. 

This affection was first described by Paxton of Chichester in 
1869, an d then by E. Wilson, who gave it its name. Pick of 
Prague, unaware of its having been long known in England, de- 



1172 



DISEASES OF THE SKIN. 




IIMM, 




Fig. 71. — Normal Hair of the Beard (Biesiadecki). 



excretory duct; b, neck of the follicle; c, dilatation of the hair follicle; 
d, external sheath of the hair follicle; e, internal sheath of the hair 
follicle; p, papilla;/, external root sheath; g, internal root sheath; 
h, cortical substance; k, medullary substance of the hair shaft; /, 
root of the hair; n, arrector pili; /, sebaceous gland; o, papillae of the 
skin; s, rete mucosum; ep, epidermis, which is continued into the 
excretory duct of the hair follicle. 



LEPOTHRIX. 



^73 




Fig. 72,-Longitudinal section of "the root of a Normal Hair from the 

beard (Unna). 



1 1 74 DISEASES OF THE SKIN. 

scribed it independently long afterwards, and many of his Ger- 
man confreres claim priority for him. 

The condition is very common; but as it rarely gives any 
trouble (though in one of my cases it was associated with in- 
tense itching), it is usually overlooked. 

Symptoms. — The hairs either of the axillae or scrotum, where 
it is in contact with the thigh, are the only regions where it has 
been observed; and since both these positions are characterized 
by warmth and moisture, these conditions are probably essen- 
tial to its production. In the most marked cases the hairs are 
brittle, and generally break off if an attempt is made to pull 
them out. On holding a hair just removed up to the light the 
borders are irregular and ragged, and it looks dull and luster- 
less, like a piece of wet string. On placing a hair under the 
microscope, nearly all along the shaft, but generally with some 




Fig. 73.— Hair of scrotum affected with lepothrix for nearly its whole 

length. X 100. 

intervals of healthy hair, and occupying the whole or part of 
the circumference, is an irregular lobed concretion, and the 
divisions being directed upwards it closely resembles the 
feather end of an arrow (Fig. 73). When the condition is 
slightly developed it consists of circular, well-defined masses, 
lying on, but not encompassing, the shaft, and often three 
times its diameter. Embedded in these masses are some of the 
fibers of the cortex, which have been separated at one end by 
the concretion (Fig. 72). In some places the fibers of the whole 
shaft are split up, and the hair may break off with a brushlike 
termination embedded in the masses, or the fracture may be a 
clean one. In the axillae the concretions are often of a red 
color, due to a micrococcus (see Red Sweat). 

The change is mainly a surface one, and the concretion is very 
resistant both to strong acids and caustic alkalies, ether and 
chloroform. With a high power the structure seems to consist 
of minute round masses. 



LEPOTHRIX. 1 1 75 

Patteson * has shown that by staining with aniline violet, and 
-decolorizing by Gram's method, a short bacillus can be demon- 
strated, which penetrates under the cortical scales, and as it is 
constant, it is probably the cause of the affection. Payne f had 
previously found bacilli in this disease. Eisner from cultures 
describes it as a diplococcus inclosed in a capsule, and that 
another diplococcus is inclosed with it in a second common 
envelope. Sonnenberg confirms this. Columbini also found 
cocci from which he cultivated diplococci and short chains or 
aggregations. An organism has also been found in relation to 
the red sweat of the axilla so often associated with this condi- 
tion of hair by Babes, Pick, Balzer, and Barthelemy, who re- 
garded the bacterium of that disease as the bacterium prodigi- 
osum; but in hairs from the scrotum the same condition occurs 
without the red color. In one case I excised a piece of the 
scrotum, but microscopical examination of the hair roots re- 
vealed nothing abnormal. 

Treatment was not very successful. Shaving and various ap- 




Fig. 74. — Hair of axilla affected with lepothrix in nodules. X 100. 

plications were tried; and as most of my patients were in the 
medical profession, the treatment was well carried out. In 
future cases I shall try shaving and sponging the axillae with 
1 in 1000 bichlorid of mercury solution, with a view of prevent- 
ing the development of organisms in the sweat. 

Piedra % (Spanish for a stone). The disease is almost con- 
fined to the hair of the head of native women who live in the 
valleys of Cauca, in Columbia; in rare instances it affects the 
hair of the head and beard in males. It consists of pin's-head- 
sized nodules, to the number of from one to ten, situated on the 

* Trans. Royal Academy of Ireland; and Reprint, J. Falconer, Dublin, 
i33g. He suggests the name " trichomycosis nodosa," but this hasalreadv 
been proposed for " piedra," and it is better to stick to the recognized 
term "lepothrix," even if its pathological signification is erroneous. 

t St Thomas' Hospital Reports, vol. xvi. p. 268. 

t Malcolm Morris, Path. Trans., vol xxx. (1879), p. 441, with plate. 



1176 DISEASES OF THE SKIN. 

surface of the hair shaft, and beginning about half an inch from 
the root, either on one side or surrounding it. 

The nodules are black, intensely hard, and rattle when the 
hair is combed; and, according to both Desenne * and Morris, 
consist of closely aggregated sporelike bodies due to fungous 
growths. More recently Juhel-Renoy, "j* by his preparations 
and cultivations, has clearly shown that the organism is a 
fungus, with spores and mycelium. 

Its origin is unknown, but in Columbia it is supposed to be 
due to the women washing their hair with a mucilaginous fluid, 
like linseed oil. 

Juhel-Renoy, as a result of experiments in cultivation, sug- 
gests as a treatment repeated sponging with i in iooo solution 
of corrosive sublimate used as hot as possible, petroleum ether 
being a useful adjunct. 

Piedra Nostras. See Tinea Nodosa. 

Chignon Fungus.J Beigel describes this as occurring as 
oval or roundish masses surrounding the hair shaft at irregular 
intervals. It was due to a fungus, which Hallier regarded as 
a species of sclerotium, calling it sclerotium Beigelanum. Beh- 
rend § is of opinion that it is identical with piedra. Beigel also 
describes another nodular disease of the hair of the head, due, 
he thinks, to a disease of the hair sac, the nodules being com- 
posed of compressed cells, like those of the inner root sheath. 
(See " Hair-eaters.") 

Tinea Nodosa, Piedra Nostras (Unna), is a name given by 
Morris and Cheadle to a case of nodular growth on the hair 

* Lancet, vol. ii. (1878), p. 165, is an abstract of Desenne's paper, read 
before the Academie des Sciences. In the same volume is much corre- 
spondence on the subject, in which the disease is erroneously mixed up 
with trichorrhexis nodosa. 

f Ann. de Derm, et de Syph., vol. ix. (1888), p. 777, and vol. i. (1890).. p. 
766, illustrated. Juhel-Renoy wishes to rechristen it " trichomycose 
nodulaire," the same name that Patteson unwittingly proposed for 
lepothrix. 

{Beigel, "Diseases of the Hair," p. in; also Tilbury Fox, "A New 
Fungus," four. Cut. Med., vol. i. (1867), p. 175. 

§ G. Behrend, " Ueber Trichomycosis nodosa (Juhel-Renoy)," Berlin 
klin. Wochensch., 1890, No. 21. Full abstract in Ann. de Derm, et de 
Syph., vol. i. (1890), p. 829. 



LEPOTHRIX. 



1177 



of the whiskers and beard of a young man. An instance of it 
came under my notice in which it affected the left side of the 
mustache of a medical man, who complained that the hairs, if 
twisted up, stuck together. On examination the hairs were 
found to be ensheathed in a concretion, which made the outline 
of the hair irregular, and was dark brown, dull, and opaque; it 
began some little distance from the root, which was quite 
healthy, and destroyed the elasticity of the hair, making some 
of them break off short, and others split. Under the micro- 
scope the nodules were seen for the most part simply to en- 
sheath the hair; but in some hairs the growth had evidently 
penetrated below the surface, and where the hair was split, to 
inclose each portion. When disintegrated and viewed with a 
higher power the concretion was seen to be composed of fungus 
spores, somewhat smaller than those of tinea tonsurans, as in 
Cheadle's case. In a case of mine Pernet found that the spores 
were in rows at right angles to the shaft of the hair, and looking 











Fig. 75. — Tinea nodosa from mustache. 

A. With low power, showing incrustation on the shaft of the hair. 

B. Small portion of incrustation with higher power. X about 300. 



like segmented mycelium bound together by a cement secreted 
by the fungus. Possibly Thin's * case of parasitic affection of 
the mustache is the same disease; Behrendf and Unna % seem 
.to have each met with a case, and Giovannini § also, or an 

* Lancet, vol. i. (1879), p. 190, with woodcut. 

\ Lancet, November 4, 1882. 

%Loc. cz't., French Abstr., p. 830. 

§ Viertelj f. de Derm. u. Syph., 1887. 



n 7 8 DISEASES OF THE SKIN. 

analogous condition. Trachsler investigated Behrend's and 
Unna's cases and found minute differences in the cultivation of 
the fungi. Shaving or clipping close for some time is the only 
remedy. 

Epithelial fragments, probably portions of the internal root 
sheath, sometimes adhere to the shaft of the hair as it grows 
up, and look like concretions. J. C. White of Boston informs 
me that it is common in America in association with alopecia 
furfuracea, and is erroneously thought to be the cause of the 
loss of hair; hence the popular name of " hair-eaters." A very 
high degree of it is often produced when chrysarobin ointment 
is employed on the scalp; a conical concretion grows up with 
♦the hair, and at first sight looks like a nit, but the hair is in 




Fig. 76. — Portion of internal root sheath adherent to shaft — the so-called 

" hair-eater." 

the center of the concretion. An extreme case resulting in per- 
manent destruction of the hair is described by Grindon.* 

Plica, which may be defined as entangling of the hair, occu- 
pied at one time a comparatively important place in works on 
skin diseases, and Alibert f devotes five plates to depicting vari- 
ous forms of it, and gives elaborate descriptions of the condi- 
tion; but since the mysterious plica polonica was proved to be 
nothing more than the product of neglect and the matting due 
to inflammatory exudation, excited by innumerable pediculi, 
agglutinating the hair together, the term is scarcely mentioned 
in dermatological works. There appears, however, to be a rare 
form, which seems entitled to the name of neuropathic plica. 
Six cases are all that I know of, one reported by J. F. Le 
Page,{ another by Wilson in relating Le Page's case, and one 
by Stelwagon, and another in a Hindoo by D. B. Pestonji.§ 
Le Page's and Pestonji's cases occurred in young women, and 
in both it came on after washing the hair in warm water, one 

* Amer. Jour. Cut. and Gen.- Ur. Dis., vol. xv. (1897), p. 256. 
f Alibert's Atlas, 1st ed., Plates VI. to X. 

\Brit. Med. Jour., January 26, 1884, p. 160. His specimen is in the 
College of Surgeons Museum, No. 374, with observations by Wilson. 
% Lancet, September 3, 1885. 



HIRSUTIES. u 79 

in a few minutes and the other after two hours. The hair was 
drawn up into a hard, tangled lump impossible to unravel, 
limited to the right side in Le Page's patient, who had very 
long hair, and in Pestonji's case to the back of the head, where 
on each side was an elongated mass very hard and firm, like 
a rope, and about the size of the fist. There was no reason 
to believe that it was an imposture, and the Hindoo woman cut 
the lumps off herself and then threw them away. Le Page 
found the most contracted hairs flattened. Stelwagon's * case 
of plica, in a woman, occupied a dollar-sized area above the 
nape, grew to four feet long in twelve years, but its mode of 
onset was unknown. 

Ohmann-Dumesnil f has met with a similar case in a girl of 
sixteen, following a chill during the catamenia. There was a 
rise of temperature, and two days after it fell matting com- 
menced, and was established in ten days, and formed a plica 
ten inches in length and one inch in thickness. The right 
cornea also sloughed and destroyed vision. The outline of the 
hair was irregular, and the hair was brittle, as in trichorrhexis. 
In a case of Dubreuilh,^ a pronounced hysteric, the distal half 
of the hair became like a negro's, but did not mat, and in a few 
weeks became normal again. A slight degree of matting oc- 
curred in another case of his. 



HIRSUTIES.§ 

Deriv. — Hirsutus, hairy. 

Synonyms. — Hypertrichiasis ; Hypertrichosis; Polytrichia; Tri- 
chauxis; Hypertrophy of the hair. 

Hairs may be increased in number or in size, either as re- 
gards length or thickness, and may grow in either normal or 
abnormal positions. In normal positions there may be excess 

* Amer. Jour. Med. Sci., December, 1892. 

\ Internal. Med. Mag., July. 1893, and abs. Brit. Jour. Derm. t vol. v. 
(1893), p. 383. 

% Dubreuilh, Annates de Derm., vol. iii. (1902), p. 368. 

§ Literature. — Wilson's " Lectures on Dermatology," 1878; Beigel, " On 
the Human Hair" (Renshaw, 1869), who records fully most of the above 
cases and many others, with woodcuts; Leonard, (Detroit, 1880). See 



n8o DISEASES OF THE SKIN. 

in length and quantity on the heads of both sexes, and in the 
beard in man. Thus Beigel relates that in Negreni, a once 
celebrated dancer, after an acute illness, the hair grew to over 
nine feet long; while at Edam is the portrait of a man whose 
beard was nine feet long, and Leonard mentions one of seven 
feet. Similar excessive growth may also be seen in the eye- 
brows, inside the nose, ears, axillae, and pubes. Then the natural 
down or almost imperceptible hair may grow excessively into 
a sort of fur, and universal hirsuties be produced. One of the 
most remarkable instances was in the oft-quoted Burmese 
Shwe-Maon and his family, where, through three generations, 
this excessive hairiness was observed, absolutely all over the 
body, except the palms and soles. There was also the Russian 
Andrian Jewtichjew and his son Feodor, figured in Ziemssen, 
and the Mexican hairy family of Ambras. Another Burmese 
instance was lately on show in this country, a male child called 
Krao. 

In abnormal positions we see it occasionally in women and 
children, who have mustaches, beards, whiskers, etc. Some of 
the best examples of bearded women are those of Julia Pas- 
trana, the Spanish dancer, whose whole body was also hairy 
(her child developed a similar condition); that of Barbara 
Urster, who lived in the sixteenth century, and had a beard 
down to her girdle; and the woman in Barnum's show who has 
a fine beard, mustache, and whiskers. These examples of 
hirsuties are selected on account of their being specially de- 
veloped; but many cases approaching them in degree as well 
as in kind are to be found in the authors already quoted, and 
elsewhere. 

In some cases two or three hairs grow from one follicle. 
Coarse, and even long hairs, in connection with moles, have 
already been described (Naevus pilosus). 

The hair does not always grow in a normal direction. Thus 
in Martinez del Salper the direction of the hair on the back 
was upward. This occurs sometimes in the eyelashes, exciting 
much irritation in the eye (trichiasis), in the eyebrows, and 
elsewhere. In the extreme hirsute cases dental defects, usually 

portraits by Beigel, also in Hebra's Atlas, Lief, ix., Taf. 7 and 8; Memoir 
by Bartel in Zeitschrift fur Ethnologie, 1879; Geyl, " Hypertrichose." 
(Hamburg, 1880). 



HIRSUTIES. 1181 

in the form of deficiency, seldom of excess, are present, as a 
rule. 

Etiology. — Racial peculiarities account for a certain number 
of cases. Thus the Burmese already mentioned, and the Ainos 
of the Island of Yezo are noted examples, though there has 
been gross exaggeration with regard to them. Unna suggests 
that the excess is really the result of defective development. 
Dark people are more liable to it than fair. Family predis- 
position is also a factor. Some cases are congenital, some occur 
later — in childhood, puberty, or in the decline of life. The 
association of congenital lumbar hypertrichosis, club-foot, and 
perforating ulcer with concealed spina bifida was first pointed 
out by Virchow, and since by Von Recklinghausen, Sutton,* 
and others. In cases published by Atgier, one brother had 
lumbar hypertrichosis, while the other had it between the 
shoulders; in each the tuft was very long. Hirsuties occurs in 
mannish women, and also in disorder or irritation of the genital 
organs or during the abeyance of sexual functions; and is often 
seen in insane women. Both in women and children it has been 
observed in association with cancer of the supra-renal cap- 
sule, t Again, it is seen in some women at puberty, during 
pregnancy, in amenorrhea, or in sterile women; but in by far 
the majority it occurs at the climacteric period and onwards. 
It is by no means necessarily indicative of bodily vigor, even 
in men. Many cases of excessive growth in normal positions 
have come on after severe illnesses, and although it is common 
to see moderate excess in strong men, some of the most nota- 
ble instances have been the very reverse. It follows local irri- 
tation sometimes, coarse hairs developing on the site of a 
blister, after using sulphur ointment, mercurial applications, 
etc. 

Prognosis. — As a rule the growth is permanent, but in a 
few cases, where it is due to a temporary cause — pregnancy, 
defective health, poulticing, etc. — it has fallen off or become 
lanugo-like again. 

* Sutton on " Spina Bifida Occulta, and its Relation to Ulcus Perforans 
and Pes Varus," Lancet, July 2, 1887, p. 5. 

•f-No. 3578 E , Museum of Coll. Surg., is "primary carcinoma of the 
adrenal," which was in life associated with abundant development of hair 
on the face and extremities in a woman, yet. thirty-two. 



ir82 DISEASES OF THE SKIN. 

Treatment. — Means for the permanent removal of superfluous 
hair can only be adopted with success when the increase or 
development is moderate, such as is present in many women on 
the chin, etc. 

The only effectual treatment is that of electrolysis, first used 
by Michel of St. Louis and Benson of Dublin (for trichiasis),, 
and afterwards by Hardaway, Piffard, and other American 
physicians. From extensive experience I can speak most highly 
of this treatment, though it is unfortunately very tedious, both 
for patient and operator. 

The mode of procedure is as follows: The patient being 
placed opposite a good light, with the head resting in a com- 
fortable position, and the superfluous hair having been cut to 
about one-eighth of an inch long, a fine needle, connected by 
means of a suitable holder with the negative pole of a galvanic 
battery, is introduced down to the bottom of the hair follicle 
by keeping the needle parallel with the direction of the hair. 
The circuit is then completed by the patient grasping the posi- 
tive pole tightly. Bubbles of froth are immediately perceived, 
and after a few seconds the patient releases her hold of the posi- 
tive pole. The needle is withdrawn, and an attempt is made to 
withdraw the hair by forceps, but without any forcible traction. 
If the hair is not perfectly loose the needle must be introduced 
again. About six to ten cells of almost any twenty-cell battery 
are usually sufficient, but the number will vary according to 
the strength of the battery. It is advisable to have an arrange- 
ment for easily altering the number of cells, and an absolute 
galvanometer to measure the strength of the current, which 
varies greatly, even at the same sitting: from three to five 
milliamperes are sufficient. The only way to secure uniformity 
in the strength of the current is to have more cells in use than 
are necessary for the current required, and then to reduce it by 
means of a rheostat. The strength of the current is also af- 
fected by the moisture of the skin and electrode, and the close- 
ness with which it is grasped or otherwise applied. 

If the needle is of steel it should be as fine as possible. Mine 
are No. 16, which I prefer either to a gold needle with iridium 
tip or to the irido-platinum one recommended by Hardaway. 
These soft metal needles are supposed to feel their way, so to 
speak, into the follicle, while the steel ones, being sharp and 



HIRSUTIES. 1 1 83 

rigid, easily pierce and go outside of it. The objection to the 
steel needle is, I think, more theoretical than practical. G. H. 
Fox recommends the finest jeweler's broach, ground so that it 
has a smooth bulbous point. From twenty to thirty hairs may 
be removed at a sitting, depending upon the skill of the opera- 
tor and upon the hairs being coarse or fine. A lens may be 
required to find the orifice of the follicle, and it is convenient 
to have a watchmaker's lens set in a spectacle frame, a four- 
inch lens in a cork mount being the most suitable. The best 
possible electrode for a patient to grasp is a carbon cylinder, 
covered with chamois leather, wetted with salt and water, and 
mounted on a handle. I have also found it advantageous to 
have a small pair of forceps attached to the handle of the needle 
holder, as it saves time and prevents the forceps being dropped 
or mislaid (Fig. jj). It is less painful to the patient if she is 
not holding the positive pole when the needle is introduced or 
withdrawn, as otherwise a sharp prick is felt. The operation 
is decidedly uncomfortable, being attended with a sense of 
burning, but few patients consider it seriously painful, and none 




Fig. 77. — Needle holder, with forceps attached, for removing hairs by 
electrolysis. In use the forceps should be turned backward instead 
of forwards, as in the woodcut, otherwise the patient may get an 
accidental scratch with the needle. 

unbearable. In no case should the needle be attached to the 
positive pole. It is less effectual, and with steel needles 
blackens the skin. In very sensitive patients I have had rubbed 
in. just before the operation, a twenty per cent, ointment of 
cocain and lanolin, and I have also injected cocain hypoder- 
mically. but the after-pain is only slightly mitigated by external 
use, and hypodermic injections are sometimes dangerous. Mor- 
ton of Xew York recommends that a solution of six grains of 
cocain in a dram of guaiacol should be introduced into the 
skin by electrical osmosis. iVccording to Lewis Jones, anes- 
thesia can be produced in four or five minutes if a little of this 



1 1 84 DISEASES OF THE SKIN. 

solution be applied to the skin by means of blotting paper, and 
on this a flat metal disc is placed, attached to the positive pole 
of the battery, and the current turned on until it reaches four 
milliamperes for a half-inch electrode. Begin with ten or fifteen 
cells and reduce the number as the resistance diminishes. A 
slight irritation of the skin is produced if it is applied for too 
long a time. This form of anesthesia would only be necessary 
for a very sensitive patient. After the operation, a small red 
papule is left at the site of removal, which soon flattens down 
to a red spot; and this, after a time, whitens down to a minute 
scar, only perceptible when carefully looked for. Hairs that 
are very close together should be removed at separate sittings, 
and it is usually advisable to wait a week between each time. 
Bathing the part operated on with warm water relieves the dis- 
comfort, and calamin lotion helps to conceal the redness, etc., 
until it has had time to subside. As a rule, the coarser hairs are 
alone fitted for operation; for lanugo growth the remedy is 
worse than the disease. The process is very successful for 
small hairy moles, but a stronger current is necessary to com- 
pletely destroy the growth. 

Owing to the theoretical simplicity of the operation it has 
largely been undertaken by ignorant and unqualified persons, 
and their unskillful manipulations have brought the procedure 
[into some disrepute, both as regards efficiency and the result- 
ing disfigurement. A good deal of practice is required to get 
the best results obtainable, but, granted the necessary skill, the 
operation is thoroughly satisfactory as regards the perma- 
nency of the removal, and there will be no marks left with the 
finer hairs, and even with coarse hairs the scars left ought to 
be so small as to be quite insignificant when sufficient time 
has elapsed for them to be quite white. 

It should be explained to the patient that a certain number, 
varying with the coarseness, position of the growth, and the 
skill of the operator, will require a second operation, owing to 
the hair papilla or its root sheaths being imperfectly destroyed. 
This is unavoidable to some extent, as the aim is not to use a 
stronger current, nor for a longer time, than is absolutely 
necessary; moreover, the direction of the root in some positions, 
e. g., in the neck, is not always in a line with the external por- 
tion of the hair, and so the root may be missed. 



HIRSUTIES. 1 185 

Finally, in a very small number of cases, disappointment is 
met with, because some of the lanugo hairs become coarse after 
the removal of their stouter fellows. Perseverance will over- 
come all these difficulties. Unnecessarily large scars result, and 
occasionally keloid, from too strong a current, from its being 
too long continued in each follicle, from too coarse a needle 
being employed, from removing hairs which grow close to- 
gether at one sitting, or from the sittings being repeated at 
too short intervals; or when epilation has been practiced by 
the patients for a long time, so that they grow erratically as 
regards direction of the root shaft, and the needle has to be 
introduced several times. 

The Rbntgcn rays have recently been strongly recommended 
by Schiff and Freund and Jutassy and others for the removal 
of superfluous hairs, hairy moles, etc. Their action is powerful 
in proportion to the intensity of the light, its proximity to the 
skin, and the duration of the exposure. As is now well known, 
prolonged and repeated exposures are liable to set up a severe 
dermatitis with ulceration most difficult to heal, and with more 
or less permanent damage to the nerve terminations. To avoid 
these evil consequences, which on a lady's face would never 
be forgiven, Schiff and Freund recommend that the current 
should not exceed two amperes, the maximum tension being 
eleven and a half volts, the spark length of the lamp not less 
than six inches, and the negative button placed eight to ten 
inches from the skin, with an exposure not exceeding ten 
minutes if the jet interrupter is employed. From ten to thirty 
sittings are usually required, the effect being cumulative; the 
coarser the hair the longer and stronger must be the exposure. 
In some cases a brown discoloration of the skin is produced, 
which disappears three or four days after the hair comes out. In 
several dark-haired people the hair became snow-white before 
it fell* out. In some of Jutassy's cases no regrowth had oc- 
curred a year after the operation. 

Although this sounds all very simple the reader is warned 
not to undertake to remove superfluous hair from the face 
before he has had experience in handling the Rontgen-ray 
apparatus, and has tried it on covered parts of the body and 
found what he can do in removing hair without producing 
serious damage, not only by a breach of the surface, but by 
75 



1 1 86 DISEASES OF THE SKIN. 

injury to the nutrition of the affected part. It is obvious also 
that as from ten to thirty sittings are required, the proceeding 
would be somewhat costly, but so also is electrolysis if the 
number of hairs is very great. Moreover, owing to idiosyncrasy 
on the part of some patients and to peculiarities in some tubes,, 
burns occur most unexpectedly, violent inflammation some- 
times setting in abruptly, from seven to fourteen days after the 
exposures have ceased. 

At the end of six to eight weeks some signs of recurrence 
will be seen, and the exposures have to be recommenced, but 
a smaller number of exposures will be required than at first. 
Several such repetitions are often necessary, and this uncer- 
tainty, and consequent expense, and the risk of burning the 
skin, limit the procedure considerably. 

High-frequency currents have also been used for the same 
purpose, but sufficient experience has not yet been gathered to 
pronounce definitely upon it. 

The alternatives to the above methods are epilation, shaving, 
and depilatories. 

Epilation with tweezers makes the hair grow coarser and 
longer. Shaving, having to be a daily performance, is viewed 
by most patients with great repugnance; and depilatories, 
while they are not more effectual than shaving, are dangerous 
applications, as they are liable to excite considerable irritation 
if the skin is sensitive; therefore I never employ or sanction 
them. Duhring recommends barii sulphidi oij, pulv. zinci oxidi, 
pulv. amyli aa oiij. Mix. Make into a thin paste with water, 
and apply on the hairy part for ten to fifteen minutes; when 
heat of the skin is felt, clean off the paste and apply a soothing 
unguent, and powder the face with starch to conceal the red- 
ness. Sulphid of sodium may be substituted for the barium 
salt. It must be repeated every few days. Many others are 
employed, but the patient should always be cautioned of the 
risk she runs in using them. Where the operation is impractica- 
ble on account of the enormous number of hairs or the ex- 
pense of it being too great for the patient's means, I recom- 
mend shaving as the safest and easiest method, and as women 
are inexpert and have a repugnance to an ordinary razor, I 
have found an excellent substitute in Auguste Bain's Rasoir 
Mecanique, the "Star" razor, or similar contrivances; they do 



ATROPHY OF THE HAIR. 1187 

not look like a razor, and the patient cannot cut herself, unless 
she tries to do so. 



ATROPHY OF THE HAIR. 

Defective nutrition of the hair may give rise to various struc- 
tural alterations, which may be symptomatic or idiopathic. 

The symptomatic cases are generally due to some constitu- 
tional disease, as syphilis, diabetes, fevers, phthisis, or other 
disorders damaging the vital powers. The hairs become dry 
and lusterless, of smaller diameter, and may split and break up 
in various ways. 

Idiopathic atrophy includes those cases in which no general 
disorders to account for it can be traced. 

Various affections come under this category, as follows: 

The hair may be simply so brittle that it breaks off with 
the slightest strain, such as brushing and combing; this is 
one form of fragilitas crinium ; or the hair may split in various 
ways. The most common event is for it to split at the end into 
three or four segments, which may extend some distance down 




Fig. 78. — Hair of beard split down to the follicle. X 4. 

the shaft. It generally occurs in long uncut hair, and there- 
fore on the scalp hair in women, but it is also frequent in long- 
bearded men. Kaposi explains it by supposing that, owing to 
the length of the end from the root, sufficient nutriment does 
not reach so far along the shaft, and the hair becomes brittle 
and splits up. The obvious remedy for such a state of things 
is to clip the hair frequently, but this is not the whole story, for 
sometimes, as Duhring pointed out, and as I have myself seen 
on the beard, the splitting seems to take place from the root, 
and looks as if there were several hairs springing from one 
bulb (Fig. 78); the cause is unknown, beyond its being a 
trophic defect. It is attended sometimes with a pustular fol- 
liculitis of the affected hairs, but whether as a cause or conse- 



1 1 88 DISEASES OF THE SKIN. 

quence is not certain. Marked cases of this kind are recorded 
by Rushton Parker * of Kendal, and by Duhring.f In one there 
was severe acne vulgaris, but not in the other. There was also 
associated trichorrhexis in Parker's case. 

In another form the cuticle only is affected, and splits away, 
giving the appearance of the hair being frayed out; it may be 
only here and there, or all along the shaft. 

Trichorrhexis nodosa (Kaposi). Synonyms. — Trichoclasis 
(Wilson); Trichoptilosis (Devergie); Swelling and bursting of 
the hair (Beigel). 

It may be defined as a green-stick fracture of the hair shaft, 
and was first described by Wilson (1849), an d then inde- 
pendently by Beigel (1855), Wilkes (1857), Kaposi, etc. 

It chiefly affects men, attacking the whiskers, beard, or mus- 
tache, more rarely the eyebrows, and hairs of the axillae, pubes, 
or scalp. I have once seen it on the front of the scalp in a lady 
who was apparently well, but had lived a good deal in hot 
climates. It began in a patch, the size of a sixpence, on the left 




Fig. 79. — Trichorrhexis nodosa from scalp of lady, set. thirty. Obj. ^, 

occul. 2 in. 

temple, and spread across, but did not quite reach the marginal 
hair on the forehead. Dr. Pratt of Leicester also sent me hairs 
from the scalp of a lady, aet. twenty-seven, in whom the disease 
had existed for six years without apparent cause. To the 
naked eye there appears to be from one to six or seven whitish 
spots, or small beadlike swellings, situated irregularly along 
the hair shaft, which may, at first sight, be mistaken for nits; 
but these are always on one side of the hair. The hair breaks 
off at these nodes with very slight traction, leaving half of it 
still attached to the growing part. Under the microscope the 
cortex is seen to be split up into its constituent fibers, the 

* Brit. Med. Jour., December 15, 1888, with engraving, 
f Amer. Jour. Med. Scien., vol. ii. (1878), p. 88, 



ATROPHY OF THE HAIR. 1189 

medulla alone maintaining its continuity; and the whole has 
been aptly compared to two short-bristled brushes, stuck end 
to end (Fig. 79). Pigment granules are to be seen between 
the fibers, and have been mistaken for fungous elements, of 
which, however, there is no real evidence. 

Beigel attributed this appearance to the formation of gas 
within the hair, which distended it to a bursting point; but the 
simple explanation of Wilson is the more probable, viz., that 
owing to damaged nutrition the hair becomes brittle, but in- 
stead of breaking completely across at once, breaks, like a 
tough stick, first at the cortex. Moreover, there is not always 
a node at the point of fracture, the shaft there being sometimes 
of less than the normal diameter. 

Paul Raymond * states that trichorrhexis nodosa is very 
common on the labia majora of women, and ascribes it to a 
diplococcus rather larger than staphylococcus pyogenes, which 
behaves quite differently under cultivation. This organism, he 
thinks, erodes the cortex of the hair, and so weakens the struc- 
ture and facilitates fracture. It is not nearly so common on 
the male genitalia, though both here and on the beard it is 
probably not so rare as is generally supposed. He found a 
similar, but smaller diplococcus on beard hairs in two cases; 
these cultivated small at first, but a few days later he found 
cocci of the same size as those from the female genitalia. He 
considers that though they are the proximate cause of the af- 
fection, they are not special to it, and are very common. He 
thinks the disease is communicable by contagion, and thus ex- 
plains McCall Anderson's cases where it seemed to be 
hereditary. 

Hodara t says that in the hair of women in Constanti- 
nople an affection very like trichorrhexis nodosa is very com- 
mon, but that it differs in that the hair between the fractures 
is split, while in true trichorrhexis the internodal part is normal. 
He is not sure, therefore, whether these affections are identical, 
but he claims to have found in his cases a small bacillus with 
rounded ends, and other forms which cultivation showed were 
degenerative forms, and he even had the " happy oppor- 
tunity " of inoculating a young girl with these organisms. 

* Ann. de Derm, et de Syfth., vol. 11.(1891), p. 568. 
\ Mai. Cutan., vol. vi. (1894), p. 641. 



1 1 9 o DISEASES OF THE SKIN. 

On the other hand, Bruhns * says that trichorrhexis nodosa 
is very common among the women of Berne, and his cases 
appear to resemble Hodara's. His conclusions are that his 
experiments are against a bacterial origin, and he argues that 
in fusiform hairs tricorrhexis occurs at the weak internodal 
point, while the argument that the disease is apparently com- 
municated to hair-brushes is answered by the fact that it only 
occurs in old brushes, where mechanical causes sufficiently ac- 
count for it. Ravence of Charleston, however, had it in his 
mustache, and found his shaving and tooth brush were affected. 
Moreover he quotes Rauber, who recorded the periodic appear- 
ance of trichorrhexis in an epileptic after fits. 

Barlow \ of Munich, after reviewing the work of Raymond, 
Blaschko, Hodara, Spiegler, and Essen, had previously come to 
the same conclusion as Bruhns, viz., that the parasitic origin 
had not been proved, and that the probabilities pointed solely 
to a nutritive change, which destroyed elasticity of the hair and 
made it liable to fracture from mechanical causes. 

On the other hand, Markusfeld \ rubbed up some of the hair 
with pumice-stone in a sterilized mortar, and from this, by 
culture, obtained a bacillus which stained by Gram's method, 
and he identified it as the same as that described by Spiegler. 

I have seen a case of a lady § whose back hair had been 
affected for eighteen months, and whose husband had had it in 
his mustache for six years. 

The treatment is not very satisfactory. Shaving is recom- 
mended, and has, when long continued, sometimes been effec- 
tual; as a rule, however, the hair grows again as brittle as ever, 
Change of climate has been successful, and in all cases efforts 
should be made to discover and remedy any defect of the gen- 
eral health. Faradizing the part might be tried. 

If the view of its parasitic origin is correct, careful removal 
of all affected hairs, if on the head, and sponging the rest with 
antiseptics, such as I in 40 carbolic lotion, or 1 in 2000 per- 
chlorid of mercury, would be the treatment indicated for the 

* Arckiv.f. Derm. u. Syph., vol. ix. (1897), p. 43. Abs. Brit. Jour. 
Derm., vol. ix. (1897), p. 290. 
f Milne h. med. Woekensckr., No. 26, 1896. Abs. loc. czt., p. 121. 
X Abs. Jour, des Mai. Cut., vol. xi. (1899), p. 205. 
§ Notes, F., 878. 



ATROPHY OF THE HAIR. 



1191 



head, but it is strange that shaving is not more uniformly suc- 
cessful when the beard is affected. 

End Atrophy.* W. McMurray of Sydney sent me some 
hairs with the condition as figured, the ends showing thinning 
and fracture. Some of the root ends were infiltrated with air, 
which, it seemed probable, was the immediate cause of the 
atrophy. McMurray, in his account of the case, stated that the 
distal end appeared of a lighter shade and bulbous ; in that case, 




Fig. 80. — Dr. McMurray 's case of end atrophy of the hair. 
D. Root end of one of the hairs, showing the hair bulb permeated with 
air bubbles. This drawing was made by reflected light, the other 
figures by transmitted light. 

it would appear that the atrophic ends I examined had broken 
off on the proximal side of the bulb. 

Monilithrix. {Synonym. — Moniliform or beaded hair.) This 
is an extremely rarely recognized condition, of which the 
first description was published by Walter Smith \ of Dublin and 
McCall Anderson. Smith described two cases of his own, and 
one of Liveing's; since then Lesser, J Payne, § Luce,|| Abraham, 

* Australian Medical Gazette, July, 1892, p. 280. 

f " A Rare Nodose Condition of the Hair," Brit. Med. Jour., vol. ii. 
(1879), p. 291, and vol. i. (1880). p. 654. 

% " Ueber Ringelhaare," Vierielj . f. Derm. u. Sy_fih., vol. xii. (1885), 
p. 655, and vol. xiii , p. 151, with plate of the same case, a girl, set. four 
and a half years; he mixes it up with the cases of ringed pigmentation. 

§ Payne, "Hairs showing Nodose Condition," Path. Trans., vol. 
xxxvii. (1886), p. 540, with plate. There were two cases, brothers, set. 
one and two years. 

|| Luce's case, quoted in Ziemssen, p. 410, in connection with delayed 
hair development, is another instance. 



n 9 2 DISEASES OF THE SKIN. 

Schiitz,* Colcott Fox, Breda, Archambault, Hallopeau, Beatty,f 
etc., have published cases, and Thin's case, J shown at the 
Congress of 1881 in London, presented a closely analogous, if 
not identical condition. 

Several members of the same family were affected in the cases 
related by McCall Anderson § and Fox and Sabouraud. 
Breda's case was an epileptic, and the formation of freshly 
affected hairs coincided with the fits. Francis' case followed 
influenza, when the girl was fifteen. 

In this affection there is a regular succession of fusiform 
nodes connected by narrow portions, giving a very distinctly 
beaded appearance, and extending from root to tip (Fig. 81). 
Nearly all the pigment is concentrated in the nodes, the inter- 
nodes being almost colorless — hence resembling, in that point, 
the alternating rings of color already described; but in that 
affection, with which Lesser has confused the one under con- 
sideration, there is no structural alteration. Nearly all the cases 
have occurred in childhood, or infancy, and most are probably 
congenital. The hair breaks off short, but always at one of the 
internodes, with a brushlike ending, and, all over the head, it is 
only about one to three inches long. 

In Francis' case the nodes and internodes were only ar- 
ranged regularly in a few of the most affected hairs; in others 
there was great variability in the number and arrangement of 
the nodes. Some hairs were unaffected, and there was no 
keratosis. 

* Schiitz, in recording another case of three and a half years, acquired 
in Cairo, gives copious bibliography, but includes ringed hair. Archiv 
f. Derm. u. Syph. y vol. liii. (1900), p. 69, with plate. The hair was spirally- 
twisted, and there were spindles in the intrafollicular portion. There 
was keratosis at the mouth of the follicle. Pernet in examining Abra- 
ham's case came to the conclusion that the spiral twist was an optical 
illusion. 

f Wallace Beatty and Alfred Scott wrote a paper in Brit. [our. 
Derm., vol. iv. (1892), p. 171. They give the abstracts of twenty-four 
cases besides their own, and consider the affection due to a tropho- 
neurosis. They describe the inner root sheath as thickened at the inter- 
nodes. Francis' case is in vol. vi. p. 363. 

% Vol. iii. p. 190, of the Trans. Internat. Med. Cong., 1881. 

§A remarkable family chart is recorded in Anderson's " Diseases of 
the Skin," p. 56, 14 out of 27 individuals in 6 generations having been 
affected; but this is beaten by Sabouraud, with 17 cases in 5 genera- 
tions, in Ann. de Derm, et de Sypk., vol. iii. (1892), p. 830. 



CANITIES. 



T 93 



Gilchrist * records a case in which moniliform hairs were 
found on the lower limbs at the periphery of some bald patches 
which formed at the age of seventeen in a healthy youth. 
Pernet found that the eyebrows and lashes were moniliform in 
Abraham's case. 

The disease is due to defective development during the forma- 
tion of the internode, while the nodal part is probably normal, or 



Fig. 81. — Moniliform hair. Obj. i in., ocul. Zeiss 3 in. 
The illustration is taken from a hair kindly given me by Dr. Walter Smith. 

nearly so, in diameter. Fox found that the beaded arrangement 
extended quite down to the root of the hair. It affects not only 
the scalp, but both the fine and coarse hairs all over the body. 
Brocq says that keratosis pilaris is present in these cases, but 
it is not present in all, and when it is, C. Fox considers it to be 
secondary. There is nothing to be done in congenital cases, 
but, when acquired, efforts should be directed to the rectification 
of any defect in the general health, and local stimulation of the 
scalp with the faradic brush. 



CANITIES, f 

(Hoariness, from camis, gray-haired.) 

Synonyms. — Grayness of the hair; Whiteness of the hair; 
Atrophy of hair pigment; Blanching of hair; Trichonosis 
cana; Trichonosis discolor; Poliothrix. 

Canities may be simply one of the evidences of senile decay 
or may occur early in life. There are all grades of it, both as 
it affects the hair individually and collectively. 

Collectively, it may exist pretty uniformly mixed with the 
normal color in one or more regions; or there may be one or 
more tufts of white, giving a piebald appearance; or the head 

* Amer. Jour. Cut. Dis., vol. xvi. (1898), p. 157. 

\Literature.— Wilson's " Lectures on Derm.," 1878. p. 166, et seq. 
Landois, " Das plotzliche ergrauende Haupthaar," Virchow's Archiv, 
vol. xxxv. (1866), p. 575, with plate, contains numerous references. 



1 1 94 DISEASES OF THE SKIN. 

may be quite white and the hair only gray elsewhere; or there 
may be blanching of the whole hairy system. 

In some cases the whiteness is only temporary; thus Wilson 
relates a case where the hair was gray in winter and recovered 
its color in the summer. Sir John Forbes also had gray hair 
for a long time, then suddenly it all turned white, and after 
remaining so for a year, it returned to its original gray. 

Griffiths of Louisville relates the case of a man, set. sixty-five; 
originally his hair was blond, it became gray when fifty-seven, 
and for three years had been quite white. He was exposed to 
intense cold, as a fireman, for many hours, his head being well 
covered with a skull cap and helmet, and twenty-four hours 
later his hair became black and oily. In alopecia areata the new 
hair is often white at first, but it nearly always regains its 
color.* 

While canities is generally slow of development it may be 
quite sudden, c. g., in a few hours. Hebra and Kaposi disputed 
this on theoretical grounds; but apart from historical instances 
the following well-authenticated occurrences, while under medi- 
cal observation, are conclusive on the point. 

In Landois' case f the hair of the beard and head of a delirium 
tremens patient became gray in the course of a night while he 
was in the hospital. Brown-Sequard observed, in his own per- 
son, that a few hairs daily became white, and in Raymond's X 
case, observed with Vulpian, the patient was a lady of neurotic 
type, who after mental strain had intense neuralgia; during a 
severe paroxysm the hairs changed color in five hours, all over 
the scalp except on the back and sides, most of them from 
black to red, but some to quite white; and in two days all the 
red hair became white, and a quantity fell off. She recovered 
her general health, but with almost total loss of hair; only a 
few red, white, and black hairs remaining on the temporal and 
occipital regions. 

The case of a Spanish cock, which was nearly killed by some 

*Amer. Jour. Cut. and Gen.-Ur. Dt's., vol. xiii. (1895), p. 376. He 
refers to several interesting cases of canities, and quotes the case of a 
woman whose hair, during a fever, became white in a week, and recov- 
ered its color in another week. 

f Loc. cit. 

% Quoted in Lancet, October 14, 1882. 



CANITIES. 1 1 95 

pigs, is also to the point. The morning after the adventure 
the feathers of the head had become completely white, and 
about half of those on the neck and back were also changed. 

Cases somewhat less sudden are more common. B. Thorn- 
ton of Margate records the case of a lady in whom the hair 
of the left eyebrow and lashes began to turn white a fortnight 
after a sudden grief, and within a week all the hair of these 
regions was quite white, and remained so; but no other part 
was affected, nor was there any other symptom. 

In Ledermann's case, a man, set. twenty-four, the hair all over 
the head and body turned white in six weeks without apparent 
cause. 

In Pincus' case, a man of thirty, the hair immediately turned 
white and remained so from the shock of a sudden grief. In 
a case of Gowers', * half the beard and mustache became white 
from meningeal hemorrhage; he died three days after the injury; 
between the normal brown and abnormal white was a narrow 
median zone of almost black hair. 

R. Jones f of Claybury asylum related the case of a melan- 
cholic patient in whom the hair became completely white all 
over the body in five weeks. The root-ends were atrophic and 
the distal third infiltrated with air. 

Individually a hair may be quite white, or, as I have seen it 
after alopecia areata, it may be colored near the root and white 



Fig. 82. — Hair from a case of alopecia areata during recovery, becoming 
gradually pigmented. 

at the distal end, the pigment extending farther in the medul- 
lary than in the cortical part (Fig. 82). The reverse of this is 
seen in the preparation No. 363, in the Museum of the College 
of Surgeons, the part near the root only being white, while the 
distal end is colored. It formed a narrow horseshoe band 
round the head, in a girl, aet. seven years. Richelot observed 
a similar phenomenon, in patches, in a girl with chlorosis; the 
newly-formed hair becoming again pigmented when the chlo- 
rosis was cured. In Falkenstein's case, a man, aet. thirtv-three, 



* Lancet, November 2, 1901, p. 1173. 
\ Lancet, March r, 1902, p. 584. 



1196 DISEASES OF THE SKIN. 

many of the hairs were white in the upper and dark in the lower 
part, in various proportions; a few were white top and bottom, 
with a brown band between, up to half an inch wide. 

Ringed Hair. A hair may also be white or colored in rings 
or bands, but this is very rare. In a case of E. Wilson's,* a 
boy, set. seven, every hair was affected; the brown segment 
was double the length of the white one, together measuring 
one-third of a line, and Wilson thought the dark represented 
the day's growth, and the white that of the night. A specimen 
of a similar defect is in St. Bartholomew's Hospital Museum. 
In a case reported by Karsch f of Moscow, a youth of nine- 
teen, all the hairs were not the same, the rings were not all of 
uniform diameter, being closest and narrowest in the middle of 
the shaft, while some hairs were half white and half brown and 
some all white or all brown. 

A case very analogous to that of Karsch came under my 
notice. It affected the mustache of a gentleman, aet. thirty-nine, 
and was associated with trichorrhexis nodosa. The hairs were 
affected in various degrees (Fig. 83). Air bubbles were in 
stellate heaps round the medulla at regular intervals in some 
hairs, but not in all, and the pigmented portions were much 
longer than the unpigmented areas. 

In a girl of seven $ the scalp hair had been affected two years 
when I first saw her; it came on after influenza and con- 
tagious ophthalmia, and five years later it was universal and 
unaltered in character. The hair from just above the root to 
the end showed a series of dark patches like Fig. 83, by trans- 
mitted light, and white by reflected light, due to air bubbles, 
with the intervals normal. The diameter of the shaft was uni- 
form, but the hair was dry and lusterless, and did not grow for 
more than eight inches. 

* Wilson's Lect.. loc. cit., No. 367-368, Coll. of Surg. Museum. 

f " De Capillitii Humani Coloribus qusedam. Diss, inaug. Gryphiae," 
1846. Quoted in full by Landois, loc. cit , with plate and microscopic 
description. 

^Private Notes, E. 759. Described in detail Brit. Jour. Derm., vol. v. 
(1893), p. 175. In vol. viii. (1896), p. 437, Galloway reports the disease in 
two brothers of eight and ten years, in whom it was apparently congeni- 
tal; and in vol. xiv. p. 86, Meachen reports a case with references to 
eight cases. 



CANITIES. 



1197 



Etiology. — Sex has no influence. It is uncommon before the 
patient has grown up, but it is seen in children occasionally, and 
a few cases with one or more white tufts have been congenital, 
and even hereditary through several generations (Morgan, 
Joynt). The youngest idiopathic case in my practice was nine 
years old, and limited to a single patch. It may be seen in a 
single patch also after long-continued and severe neuralgia, in 
multiple symmetrical patches as a part of leukodermia, and as 
irregular piebaldness during recovery from alopecia areata. 
The lower grades of gray hair, and more rarely complete cani- 
ties, are seen after specific fevers, especially scarlatina and 
typhoid, and after any prolonged strain or drain, mental or 
bodily, of the general system. 

Premature grayness is also frequently due to family pre- 
disposition. The influence of a nervous shock, especially from 
intense fear or grief, both for gradual and rapid blanching of 
the hair, is generally admitted, e. g., rapid whitening of the hair 
has been observed in some who suffered from melancholia. 
Another instance of nerve influence is when the eyelashes have 

a 



Fig. 83. — Ringed hairs. X 125. 

a, from mustache; b, from scalp of another patient, viewed by trans- 
mitted light. By reflected light the darkest parts are shown to be 
air, the pigment being between these collections of air globules; the 
diameter of the shaft is slightly increased where the air is situated. 

turned white in sympathetic ophthalmitis, after destruction of 
the opposite eye. Instances are reported by Nettleship,* 
Hutchinson, Jacobson, etc. 

Pathology. — Ehrmann's explanation of the mechanism of hair 
pigment discoloration has already been set forth under the 
pathology of pigmentation in general, and is probably the cor- 
rect one for senile and other gradually developed canities; but 
the theory of Landois and others, that air bubbles form in the 
* Lancet, December 22, 1883, Rep. of Ophthal. Society. 



1198 DISEASES OF THE SKIN. 

substance of the hair, enough sometimes to produce perceptible 
bulgings and to conceal the pigment, which, however, is still 
present, best explains the cases of sudden blanching. 

Prognosis. — As a rule, the prognosis is bad; the hair gen- 
erally remains white for the rest of life; still, as will be seen 
from the cases related, recovery of the normal color does occur, 
and is most likely to happen when the color has been lost 
after some severe illness, or some other definite and remarka- 
ble cause. A remarkable case of restoration is related by W. 
O'Neill * of Lincoln. A man who was both bald and gray, set. 
fifty-nine, became suddenly hemiplegic, and remained so; three 
and a half years later dark hair began to grow on the bald 
patch, and the gray hair of the head and beard began to fall 
off, and was replaced by dark brown hair, until the whole head 
and beard were the same as when a young man. The man was 
a great chlorodyne drinker. 

Even in congenital cases, with tufts of white hair, it has in a 
few instances become colored. Unless the patient is over fifty 
canities after alopecia areata is generally only temporary. 
Where there is a hereditary tendency to early grayness the 
prospect of recovery is very slight. 

Treatment. — But little can be done by way of treatment; no 
drugs or treatment have any direct influence on pigmentation 
production or distribution in the hair. Where it has arisen 
from exhausting disease or nervous strain, general tonics and 
hygienic measures may lead indirectly to restoration. Hypo- 
dermic injections of pilocarpin nitrate or hydrochlorate 
gr. i-io, gradually increased, or tincture of jaborandi TTLx and 
upwards internally, might be tried. Faradization with the wire 
brush electrode also offers a chance for some cases. Arsenic 
and mix vomica as nerve tonics may be of some service. Dye- 
ing the white hair may sometimes be an improvement. 

* Lancet, July 20, 1889. See also cases by Graves, "Studies in Physi- 
ology and Medicine," 1863, p. 335. 



DISCOLORATION OF THE HAIR. n 99 



DISCOLORATION OF THE HAIR.* 

Several instances of change of color, other than canities, are 
on record. One of the most remarkable is Prentiss' case. The 
patient was suffering from pyelo-nephritis and anuria, for which 
pilocarpin hydrochlorate was subcutaneously injected for over 
two months. At the end of twelve days the hair, which was 
light blond, began to turn, and continued to get darker for 
some time after the medicine was stopped, and at the end of 
six months had become nearly jet black, both on the head and 
axillae; the hair was also coarser, and the eyes had changed 
from light to dark blue. 

Alibert and Beigel relate cases of women with blond hair 
which all came off after a severe fever (typhus in one case), 
and when it grew again was quite black. Alibert also saw a 
case of a young man who lost his brown hair after illness, and 
after restoration it was red. In an epileptic girl of idiotic 
type, with alternating phases of stupidity and excitement, in an 
asylum at Hamburg, the hair in the stupid phase was blond 
and in the excited condition red; the change of color taking 
place in the course of two or three days, beginning first at the 
free ends, and remaining of the same tint for seven or eight 
days. The pale hairs had more air spaces than the darker ones. 
There w T as much structural change in the brain and spinal cord. 
Smyly of Dublin reported a case of suppurative disease of the 
temporal bone, in which the hair changed from a mouse color 
to a reddish-yellow; and Squire records a congenital case in 
a deaf mute, in which, on the left side, the hair was in light 
patches of true auburn and dark patches of dark brown, like a 
tortoiseshell cat; on the other side the hair was dark brown. 
M. Mayer's case was a boy whose hair was a clear blond, but 
at the junction of the hair and nucha there was a band of red- 
dish hair about two fingers in width. This was the third occa- 
sion in which the phenomenon had appeared. The first was 
two years ago, during convalescence from an illness, and the 
discoloration lasted about three weeks; it recurred in six 

* Literature. — See paper by G. F. Jackson in Amer. Jour. Cut. and 
Ven. Dis., vol. ii. p. 173. Phil. Med. Times, 1881, xi. 6gg. Lancet, 
June, 1881, quoted by Landois, pp. 583-84. Changes after death from 
dark brown to red, and from red to gray, have occurred in rare instances. 



1200 DISEASES OF THE SKIN. 

months, and this last time had lasted three weeks. Analogous 
conditions sometimes occur in lunatics. 

Accidental discolorations occur of various tints, c. g., blue 
hair is seen in workers in cobalt mines and indigo works; 
green hair in copper-smelters; deep red-brown hair in handlers 
of crude anilin; and the hair is dyed a purplish-brown when- 
ever chrysarobin applications, used on the scalp, come in con- 
tact with an alkali, as in washing with soap. 

ALOPECIA. 

Deriv. — d\G07rt}£; ; a fox, because partial baldness is common in 

that animal. 

This is the generic term for all kinds of baldness, irrespective 
of the cause. 

It may be complete or partial, and the latter may be in the 
form of general or local thinning; or in bald areas of various 
size. 

The varieties of baldness are classified etiologically into con- 
genital, senile, and premature, the last being idiopathic or 
symptomatic. 

Congenital Alopecia. Although known to Hippocrates, this 
condition is rare, and when present is seldom complete, the hair 
being only scanty, patchy, or lanugo-like. Unless the hair folli- 
cles are absent, as in the complete cases of Schede * and 
Ziegler,f the baldness is seldom permanent, partial or com- 
plete growth usually taking place eventually. The skin itself, 
where the hair ought to be, may be normal, or there may be 
abnormalities of development in the skin as a whole, in the 
nails or in the teeth, and the secretions of the skin may be 
defective. A family predisposition to a scanty development of 
hair is not uncommon, and extreme abnormalities of the same 
character have been noted in members of the same family for 
several generations. There are even races like some Australian 
aborigines who are hairless. Illustrative cases and references 
are given in the footnotes. f 

* Archiv f. kli?i. Chir., Bd. xiv. (1872), p. 158. 

\ Archiv f. Derm. u. Syph., Bd. xxxix. (1897), p. 213. Three colored 
plates of sections of skin ; numerous references to date. 

JThurnam, Med. Chir. Trans., vol. lix. (1886), p. 473. Two cousins 



ALOPECIA. 1201 

Senile Alopecia (Senile Calvities). Here, as Pincus and 
Neumann have shown, the loss of hair is only a part of the 
general atrophy of the skin structures. The age at which it 
comes on varies greatly, and all the other hairy regions of the 
body which share in the cutaneous atrophy are affected, but 
rarely to so marked a degree as in the scalp. 

Seborrhea is also an important factor in a large proportion 
of cases. 

The baldness begins first at the posterior part of the vertex 
and then spreads forwards and backwards until the whole 
crown is denuded, leaving only a fringe of greater or less width 
at the sides and back. 

The theory to explain this distribution is that the scalp at 
.the crown is much thinner than at the sides, and that the 
nutrition of the hairs at the vertex is therefore more easily in- 

who had each only a lanugo growth on the body and head, only four 
teeth (molars), and who never perspired or shed tears. He quotes other 
cases. A girl of four years came under me who had been born without 
hair or nails, the nails began to grow, but abnormally, in a week, the hair 
not for three years, and there was atrophy of the skin generally. In my 
Atlas, Plate XC, Fig. 13, her nails and hand are shown, and there is an 
account of the case. In Hutchinson's case, also a boy, set. three and a 
half years, there was congenital baldness of the scalp and atrophy of the 
skin generally and absence of the mammary glands. The mother had 
been bald from alopecia areata from the age of sixteen years. Med. 
Chir. Trans., vol. lix. (18S6), p. 473. In Paul de Molene's case there was 
no abnormality besides the baldness (there was a scanty fine down even 
at birth), but the mother had had alopecia areata for three years when 
nineteen years old, and her son when six years old also had alopecia 
areata. Annates de Derm, et de Syph., vol. i. (1890), p. 548, several refer- 
ences. F. Pincus in recording a case gives full bibliography. Archiv 
f. Derm. u. Syph., vol. 1. (1899), p. 347. Audry, Mai. Cut., vol. xiv. 
(1902), p. 9. records four cases of his own. Nicolle and Halipre relate 
that in one family there were thirty-six individuals in six generations 
with defective hair and nails, Some were born without hair or nails, 
others had lanugo. growth and defective nails with or without chronic 
onychitis. Annates de Derm, et de Syph., vol. vi. (1895), Aug. -Sept. 
Abs. Brit. Jour. Derm., vol. viii. (1896), p. 417. Charles J. White met 
with a similar series of cases, but not so extensive, presenting similar 
clinical features. Amer. Jour. Cut. and Gen.-Ur. Dis., vol. xiv. (1896), 
p. 220, with photographs. Hill, J. H., " Hairless Australian Aborigines," 
Brit. Med. Jour., vol. i. (1881), p. 177. I have a photograph of an adult 
African negro absolutely hairless from birth. It was sent me by a 
former pupil, but I have lost his letter with notes of the case. 

76 



1202 DISEASES OF THE SKIN. 

terfered with. A similar explanation is put forward to account 
for the comparative rarity of senile baldness in women, their 
scalp being thicker and containing more fat. 

Idiopathic Premature Alopecia (Alopecia Simplex). As a 
rule, in this form, the distribution is the same as in senile 
alopecia, but sometimes the loss begins at the temples, the hair 
line receding until there is only a central crest left, which also- 
ultimately disappears. 

It may begin at any time after puberty, though not often 
before twenty to twenty-five years of age; this again is much- 
less frequent in women. 

According to Pincus, instead of being, like the senile form, 
a part of the atrophy of the whole skin, there is increase of 
the connective tissue, which contracts and compresses the hair 
follicle, and thus produces its atrophy. 

There are, however, very strong reasons for believing that 
idiopathic baldness is exceptional, nearly all being really due to 
seborrhea. In this I agree with G. T. Elliot,* who examined 
carefully 344 cases in his private practice of premature baldness, 
and deducting 24 cases due to general conditions, found sebor- 
rhea, or, as he calls it after Unna, eczema seborrhoicum, in 
316 cases, and that 64 per cent, occurred under thirty years of 
age. Four cases showed heredity as an uncomplicated factor, 
but there can be no doubt that seborrheic baldness may be 
observed to affect the males of a family at an early age for sev- 
eral generations, often also with premature grayness. Proba- 
bly what is really inherited is a tissue similarly favorable to the 
growth of the seborrheic microbe. 

Symptomatic Premature Alopecia. This may be temporary 
or permanent, the loss may be either sudden or gradual, and 
dependent upon local or constitutional causes. From constitu- 
tional causes it is seen after or during a severe illness, especially 
fevers, in cachectic conditions, such as phthisis, diabetes mel- 
litus, myxedema, syphilis, leprosy, etc., or it may be of neurotic 
origin, as after violent shocks, or intense or prolonged anxiety. 
The local causes are very numerous, the most common being: 
1. Seborrhea of the scalp, which may lead to permanent 

* New York Medical Journal, October 26, 1895. 



ALOPECIA. 1203 

baldness; women are as liable to it or even more so than men, 
it being the chief of all causes in both sexes. 

2. Most inflammatory diseases of the scalp, if severe or pro- 
longed enough, such as erysipelas, smallpox, psoriasis, eczema, 
etc. The loss varies with the severity of the affection, and is 
usually recovered from after the removal of the primary affec- 
tion, unless suppuration has been so free as to destroy the 
follicles. 

3. It may be seen in lupus erythematosus, in morphea, and in 
folliculitis decalvans; in all these the baldness is permanent. 

4. Brocq * considers that the keratosis pilaris seen in ich- 
thyosis may in some cases affect the scalp also, and lead to 
permanent atrophy of the follicles, and falling out of the hairs 
involved, which are replaced by lanugo hairs, round which 
slightly reddened papules may then be visible. It is, he thinks, 
a fruitful cause of baldness in infancy, adolescence, and even 
maturity, and may occur without ichthyosis. He considers the 
ulerythema ophryogenes of Taenzer is a form of this keratosis 
pilaris capillitii, of which the ultimate result is a cicatricial 
atrophy of the skin, and that monilithrix is also due to it. 

5. In parasitic diseases, such as tinea tonsurans, where the 
loss is temporary only, except after severe kerion ; and in favus, 
where the loss is often permanent, owing to pressure atrophy, 
produced by the favus cups. 

6. Syphilis may produce it either early in the disease, as a 
part of the general cachexia, or consequent upon some erup- 
tions of the scalp, while in the later stage it may be due either 
to seborrhea, which is a very common affection after syphilis, 
or from ulcerative lesions. 

In the first two the loss is only temporary and causes a gen- 
eral thinning, with lack of nutrition, shown by the straight, 
dry, and lusterless condition of what remains. In the latter 
forms it may be permanent from seborrhea, and will certainly 
be so after ulceration. 

7. Local injuries — a blow producing a bruise, the sting of a 
bee (Wilson); friction — c. g., from the headgear in women or 
from their straining the hair in abnormal directions. 

8. Both the neurotic and parasitic forms of alopecia areata. 

* Ann. de Derm, et de Syph. t vol. iii. (1892), pp. 773 and 1197; also in 
his treatise, p. 384. 



1204 



DISEASES OF THE SKIN. 



9. The administration of thallium acetate for the excessive 
sweating of phthisis has been followed by extensive loss of hair 
all over the body, in so many instances, that there can be no 
doubt that it was due to the drug. Giovannini could find noth- 
ing by microscopic examination in the skin or hair to account 
for it. The loss is only temporary. 

ALOPECIA SEBORRHOICA. 

Although the subject of seborrhea has already been dis- 
cussed (p. 1 1 10), its importance as a cause of premature bald- 
ness is so great that some points deserve further attention in 
this section of diseases of the hair. As here employed the term 
is not restricted to the oily form. The distribution of sebor- 
rheic alopecia is the same as that described under so-called 
idiopathic baldness, namely, the temples, vertex, and the frontal 
hair line. 

This distribution is combined with the presence on the scalp 
of either an excessive greasiness of the surface from oily sebor- 
rhea; or fine glistening powdery scales; or greasy scales lying 
closely on the scalp and requiring to be scraped off; yellowish 
fatty matter, looking like pale yellow wax, sometimes evi- 
dently largely made up of scales, at others giving the impres- 
sion of being only dirty yellowish wax. The waxy substances 
can easily be scraped off with a blunt instrument, the skin be- 
neath being white and shiny. This abnormal secretion is most 
marked on the vertex, being rubbed off in washing at the tem- 
ples and forehead, and being absent or scanty, as a rule, at the 
occiput and sides, parts which rarely become bald from sebor- 
rhea alone, i. e., without active accompanying inflammation, 
although in long-standing cases considerable reduction in the 
width of the remaining fringe may take place. 

I have, however, seen general thinning in a young man reach- 
ing down to the lowest border all round in a seborrhea in which 
the fatty deposition was limited to the infundibular orifice of the 
hair follicles, and from many of which a comedo-like plug could 
be expressed. 

I have also seen a few cases of a sickle-shaped alopecia just 
above the ear, with marked horny sebaceous plugging at the 
follicular orifices, seborrhea of the vertex being also present. 



ALOPECIA SEBORRHOICA. 1205 

In some of the most troublesome cases of general progressive 
thinning there is nothing but a true seborrhea oleosa, the scalp 
being constantly bathed in oily secretion of a dirty yellow color 
when scraped off. Both in this and in the drier form there 
may be very marked funnel-shaped depressions round the hair 
follicles which are filled with fat. In some cases the seborrhea 
is limited to these depressions, the surface being clean. Al- 
though this cupping at the hair follicles occurs chiefly in severe 
cases it may be partially or completely recovered from. 

According to Sabouraud this oily form occurs almost ex- 
clusively in males, but this is by no means the case in my experi- 
ence, as I have met with it fairly frequently in women and even 
girls under twenty-one; and although there is not complete 
calvities as in men, the thinning is very conspicuous when 
no artificial supplements are used, and it is the form most 
rebellious to treatment. I also do not consider that there is 
any real etiological distinction between temporal and coronal 
baldness. Although the temporal denudation is often more ad- 
vanced in degree the vertex is always more or less thinned also, 
and is on its way to being completely bare. 

Pathogeny. — On clinical grounds the presence of micro- 
organisms with a pathogenic role has long been inferred.* 

Bacteriology. — Malassez as far back as 1874 described minute oval and 
round spores which were abundant in the horny layers and penetrated 
into the follicle nearly as far as the sebaceous orifices. Bizozzero (1884) 
confirmed this, and has been followed by Boeck, Pikhelharing, and 
others. 

Then came Unna (1890), f who with improved knowledge and means of 
investigation, while confirming previous observations, showed that the 
organism should be referred to the schizomycetes, and named the chief 
organism from its shape, the flask or bottle bacillus. There is also a tiny 
bacillus to be found in the sections. Van Hoorn has gone over the same 
ground, and found the same organisms, and described the small bacillus, 
which he cultivated, as very abundant and constant in the scales and 
hair follicles. 

W. H. MerrittJ (1895), working on G. T. Elliot's cases, describes two 
kinds of diplococcus morphologically similar, but while both are aerobic 

* Yet Sabouraud says that before he demonstrated his microbacillus in 
1897, neither he nor anyone else "had the idea that calvites could be 
a microbian disease." 

f " Histopathology," p. 233. 

%New York Med. Jour., October 26, 1895. 



1206 DISEASES OF THE SKIN. 

and non-liquefying, No. i is non-chromogenic, and No. 2 is chromogenic. 
Inoculation with No. 1 produced a reddened area with dry white scales; 
with No. 2 yellowish spots appeared, resembling some forms of sebor- 
rhea; and with a mixture of 1 and 2 on the fourth day, gave rise to areas 
with typical crumbly greasy scales. He also found a bacillus with 
rounded ends, but probably of non-pathogenic influence. These experi- 
ments would seem to settle the matter conclusively, and the yellow color 
often seen would be accounted for by No. 2 * diplococcus, but another 
organism was described by Sabouraud f (1897), after laborious researches, 
and he affirms that the specific organism is a micro-bacillus (the acne 
bacillus of Unna), punctiform and very like a coccus in its young forms, 
but in its adult form it is one // long and a half // in diameter. It is best 
stained by the Gram-Weigert method. 

This he has succeeded in cultivating in a special acid peptone-agar 
medium, but not always in pure culture from the first. The yolk of egg 
is also an excellent medium. Whether in oily seborrhea of the scalp, the 
face, or in the comedo, this micro-bacillus is the one fundamental organ- 
ism. I am glad to find he emphasizes what I had observed clinically, 
that the pure oily seborrhea capitis was the most destructive to the hair 
and the most rebellious to treatment. In the more waxy forms there is 
a mixture of the oily seborrhea and scales, and then there is present not 
only the seborrheic micro-bacillus, but the bacillus spores of Malassez, 
which is the bottle bacillus of Unna, and a staphylococcus. 

In the scaly form there are innumerable corneous scales, pityriasis or 
seborrheic eczema of Unna, but no seborrhea, therefore, no micro-bacilli, 
but bottle bacilli, and cocci. 

The above may be put almost algebraically: mb = oily seborrhea ; 
mb + bb = waxy seborrhea; bb -|- sc = pityriasis without seborrhea, 
Q. E. D. Sabouraud. Yet Jacquet holds that the increased oily secretion 
is a normal result of puberty, and the bacilli are therefore banal organ- 
isms. Their constancy under the above conditions contradicts this, 
replies Sabouraud. 

The mechanism of seborrheic alopecia as unraveled by Sabouraud is 
as follows: The specific micro-bacillus invades the follicle by the follicu- 
lar orifice, it multiplies and forms a thin lamina made up of microbes 
which separate the hair shaft from the wall of the follicle and descends 
almost to the level of the orifice of the sebaceous duct. 

The epithelial irritation excited in the neighborhood produces horny 
layers which encyst the microbian colony and form what Sabouraud calls 
a cocoon, which is attached to one side of the hair shaft. The conse- 

* In the Museum of the Coll. of Surg.. No. 34T, Derm. Series, there is 
some hair of a lady, set. eighty-two. The white hair is stained golden 
yellow by an abundant gummy secretion from the scalp. It came on 
after an attack of jaundice, and had persisted for five years. It also 
stained her linen and had a disagreeable odor. 

\ Les Annates de V Ins tit lit Pasteur (1897). See also his " Seborrhee, 
Acnes, Calvitie (1892), p. 164. 



ALOPECIA SEBORRHOICA. 



1207 



quences of its presence manifest themselves in sebaceous hypersecretion 
followed by glandular hypertrophy to three or four times the normal 
size, and progressive atrophy of the hair papilla. Lymphocytes and 
giant cells in small quantity are found round the microbian utricle, round 
the neighboring vessels, in the angle of the arrector pili and shaft, and 
round the base of the follicle and the papilla. The functions of the latter 
are interfered with, the pigment is no longer conveyed to the hair cells, 
the medullary cells of the shaft are no longer produced, the diameter of 
the shaft is diminished, and hence the adult characters of the hair are 
lost and the new hairs have neither pigment nor medulla; finally, even 
this weak substitute is not produced, hair production ceasing altogether 
and the papilla itself disappearing. 

Unnaf explains the process differently. The follicular orifice is dilated 
by abnormal horny layers round the hair into an infundibulum, with its 
.apex at the mouth of the sebaceous glands. The root sheath is retained 
in the follicle and thrown into folds which press on the hair and tend to 
loosen it. The sebaceous glands are very little altered at first, but 
ultimately their secretion is arrested, and the gland is distended, as the 
secretion cannot escape as it should. 

The loss of hair is not due to loosening of the root-sheath or atrophy 
•of the papilla. The causes are due to changes in the upper and middle 
layers of the follic.e, leading to diminished hair formation, and not to 
atrophy of the papillary hairs. New smaller papillae are formed, or there 
may be a shortened old epithelial process with a remnant of the papilla, 
£l lanugo hair only resulting, and from the increasing difficulty of hair 
formation it ultimately reaches the vanishing point. 

The hairless follicles are finally converted into sebaceous glands, and 
sometimes into sebaceous cysts. 

Personally I incline to Sabouraud's explanation, but it has not as yet 
quite acquired the status of a dogma. 

Prognosis. — Seborrheic alopecia, if untreated, goes on slowly, 
as a rule, but surely, until the whole vertex is denuded of hair, 
a fringe of hair being left at the sides of varying width in dif- 
ferent cases, but wider behind. Under treatment the result 
varies according to whether the patient seeks advice early or 
late in the disease. In the latter, more or less of the vertex 
may be permanently bald, while the process in the remaining 
hair may be arrested and a little renewed hair be obtained. 
In an early stage there may be almost complete restoration 
of the shed hair, but inasmuch as the disease is due to a tissue 
proclivity to a microbe, and this is deep down in the upper part 
of the follicle, a lasting cure is rarely obtained, and the patient 
has to apply a microbicide once or twice a week for an in- 

* " Histopathology," p. 234. 



1208 DISEASES OF THE SKIN. 

definite period after the daily treatment has produced an 
apparent cure. 

Treatment. — The principles of such an internal treatment as 
may be required in some cases is referred to in the chapter on 
Seborrhea, and only the special measures for the scalp which 
are usually all that is required, will be discussed here. 

Applications may be made in the form of ointments or lo- 
tions, and they are all, in these days, microbicides. The time- 
honored cantharides occupies a very subordinate position, for, 
as a rule, if the microbe and its immediate consequences are 
removed, the hair is nearly always ready enough to grow. The 
great majority of patients infinitely prefer lotions to ointments, 
and as it is often difficult to make them use ointments for any 
length of time I generally prescribe lotions. 

If there is present a fatty or waxy seborrhea, a preliminary 
cleaning with soft soap, spirit, and thymol (F. Lotions 8) is 
desirable to facilitate the absorption of the watery lotion. It 
may be repeated once in two or three weeks. After rubbing it 
on with wet flannel it should be rinsed off with tepid water, the 
hair dried, and one or other of the following lotions immedi- 
ately sponged in: 

The formulae that may be written for the daily lotion are very 
numerous, and I will only give a few which I have found useful. 
Acidi acetici §ss, resorcin oij, eau de Cologne §ij, aq. rosae ad 
5viij ; ol. ricini oss mixed with the eau de Cologne, or a little 
glycerin may sometimes be added. The hair should be parted 
in small portions and the lotion well rubbed in to the scalp 
with flannel or sponge, the greatest attention being paid to the 
vertex and its neighborhood. 

Sodae sozoiodolatis oiij may be substituted for the acetic acid 
and resorcin. Sodae hyposulphis may also be used, but the 
nascent sulphur lotions are still better (F. Hair Lotions 51). 
The sozoiodolate and nascent sulphur lotions are preferable for 
the oily forms to the acetic acid and resorcin, which acts best 
in the drier form. Where there are signs of commencing in- 
flammation of the scalp a lotion of glycerini plumbi subacet. §i, 
liq. carb. detergens §ss, acquae rosae ad ^viij is often one of the 
best applications. 

Sometimes when the scalp is very dry it is desirable to pre- 
scribe a pomade to be used whenever the head is shampooed, 



ALOPECIA AREATA. 1209 

such as hyd. perch, gr. 1, aqua rosse 5j, lanolin oij, adipis ad §j, 
or, hydrarg. biniodidi, pot. iodid aa gr. ij, with the same vehicles. 
Here it may be observed that daily washing of the head, as 
practiced by many men, is nearly always injurious. 

When ointments are prescribed they are generally some 
preparation of mercury, the diluted nitrate, yellow oxid, or 
ammoniated mercury, or they may contain sulphur, resorcin, 
or salicylic acid. Vasogen iodin ten per cent. 3j, heavy paraffin 
oil §j, is often serviceable. 

A good formula for obstinate cases in the scalp I have found 
to be ung. hyd. nit. 5j to 5iv, ol. cadini 3j, ol. olivae oij, lanolin 
5iv, misce; this is to be well rubbed in every night, and, if the 
daily avocations require it, washed off in the morning with 
borax oij, to water Oj, and then a little almond oil may be 
rubbed in, or the ung. hyd. oxid. flav. may be used instead of the 
nitrate, with or without the oil of cade. Where there is hy- 
peremia a soothing remedy may be necessary at first. 



ALOPECIA AREATA. 

Synonyms. — Porrigo decalvans; Tinea decalvans; Area Celsi; 
Alopecia circumscripta; Fr., Pelade. 

Definition. — An acutely produced baldness, with complete 
denudation of the affected parts, primarily in round patches, but 
which may spread into large areas, or even over the whole hairy 
system. 

At least four classes of cases are recognizable under the term 
alopecia areata. 

In the first are universal cases, usually of rapid development, 
and not necessarily in patches. 

In the second are those cases with one or more patches in 
the course of a nerve, or on the site of an injury. 

In the third are cases of the common type, in patches or 
bands of irregular distribution, and with characteristic !) hairs 
at the border of the spreading patches. 

In the fourth seborrhea capitis is a very conspicuous feature 
and is probably in etiological relationship. 

The first two classes are undoubtedly of tropho-neurotic 



12 io DISEASES OF THE SKIN. 

origin, and the third and fourth are, in my opinion, parasitic, 
and form the largest proportion of the cases. 

The first two, therefore, form a group which might be com- 
prised under the head of " Alopecia Neurotica," with sub- 
groups universalis and localis, and the last two would form a 
group of alopecia parasitica, one of which is certainly of sebor- 
rheic origin, and Sabouraud says both are so. 

Class I., Alopecia Universalis, comprises those cases in which 
the alopecia is universal, and in which the hair does not neces- 
sarily come out in patches, but there is general falling off, often 
very rapid, and accompanied in some cases by changes in, or 
even falling off of some or all of the nails, as in the following 
instance: A boy, aged eight years, without any apparent cause 
or preceding ill-health except a poor appetite, within ten days 
lost the whole of the hair all over the body, together with all 
the finger and toe nails. Three years later, when I saw him, 
there was not a hair or nail present, and the nail bed was 
rough and irregular, as if the nail had been torn off, leaving 
a little horny matter behind. In a second case, a boy of four- 
teen, the whole of the hair had come off some time previously, 
soon after a fall from a tree on to his head. In a third, a girl 
aged two years fell nine feet from a window. She did not 
recover complete consciousness for three weeks, and a week 
after regaining her senses the hair began to come out on the 
left side of the head, and she became quite bald in a week, with 
the exception of a small tuft at the left occipito-parietal suture; 
the nails were unaffected. A year and a half later the hair was 
returning, leaving circular bare patches like a commencing 
alopecia areata. Rapidly universal cases after worry, fright, 
and injuries to the head have been recorded by Tyson, Duck- 
worth, Cooper, Todd, Holmes, Collier, and others in this coun- 
try and abroad. In some the hair began to fall out in patches; 
in others it came out indiscriminately, or even in masses. In 
a captain, whose ship was struck by lightning, and who sus- 
tained scalp wounds, it began the very next day on the beard, 
and then the scalp and the rest of the body were denuded; two 
months later the nails scaled off from the fingers, but not from 
the toes. In several other of the above cases some or all of the 
nails were lost. In one of Tyson's cases the big toe and 



ALOPECIA AREATA. 



I2II 



thumb nails alone escaped. In a case of Bidon's * a healthy boy 
lost all the hair of his head a few hours after a transitory 
fright, the eyebrows and lashes followed in a few days, and the 
loss was permanent. In a case of Boissier's a father saw his 
child killed, as he thought. The next day the hair began to fall 
out of the scalp and face, and alopecia was complete in a week. 
Regrowth immediately began, but the hair came back quite 
white and remained so. In a very large proportion of these 
loss of hair is permanent, and the course is for the most part 
rapid. In the following instance it was more gradual. A 
woman, aged thirty-five, began to lose her hair during preg- 
nancy, nine months before I saw her, but it was several months 
before the alopecia was complete on the scalp, with the ex- 
ception of a few straggling hairs on the back. The eyebrows 
and lashes were partially lost; some of the nails were deeply 
furrowed, others were half separated from the matrix, while 
others again were flattened, with slight pitting. The universal 
cases of this type are really very rare, although, owing to their 
striking character, a considerable number are recorded in der- 
matological literature. 

In this and in the other forms where a sufficiently large area 
is affected the skin is whiter than normal, preternaturally 
smooth, and soft to the touch when pinched up; it is evidently 
thinned, and having lost much of its elasticity, pits slightly on 
pressure. The loss of the eyebrows and lashes produces a strik- 
ing and characteristic aspect. The downy hair of the body is 
also often lost. 

Class II., Alopecia Localis seu Neuritica, comprises cases of 
baldness occurring in one or more patches at the site of an 
injury, or in the course of a recognizable nerve. These are very 
few in number comparatively, but there are many on record. 
In a woman with melancholia, aged thirty-four, whom I saw 
with Dr. Savage at Bethlehem Hospital, there were white patches 
of hair in the course of the left supra-orbital, and one between 
two or three inches in diameter was almost bare; there was no 
history of them obtainable. Many cases have been preceded 
by severe and persistent neuralgia, and even when the hair is 
restored on the bald patch it not infrequently remains white. 
*Jonr. Mai. Cut., vol. xi. (1899), P- 37 2 - 



12 12 DISEASES OF THE SKIN. 

In Pontoppidan's case, a girl, aged ten, had some glands re- 
moved in the left carotid region, which was followed by ocular 
paralysis, indicating injury to the sympathetic nerve, while loss 
of hair in areas on the back of the head took place, and six 
weeks later the whole back of the head became denuded in the 
region corresponding to the domain of the great and small oc- 
cipital nerves, and the posterior branch of the great auricular. 
Within three months the hair began to grow again. Joseph ex- 
cised the second cervical ganglion in the cat and rabbit, and 
this operation was followed by alopecia patches in the territory 
of the second cervical, the occipital, and the great auricular 
nerves; but the results were not uniform, and his experiments, 
though partially confirmed by Mibelli, are not accepted as con- 
clusive; for Behrend and others have not been able to get the 
same effects. If my theory that there is a neuritis in all this 
class is correct, the experimental discrepancy might be ac- 
counted for by the presence or absence of that factor, as it is 
probable that in the most careful experiments the neuritis would 
be avoided. In corroboration of the neuritis theory two cases 
related by J. Collier * may be cited. In one a schoolboy re- 
ceived a blow on the left ear in a fight ; it was followed by severe 
neuralgia, which lasted a fortnight, and then a large bare patch 
was noticed in the left parietal region; in about a month the 
hair grew again, but was quite gray. In the other case a blow 
with a cricket ball was followed by a bald patch one inch above 
the injury; the hair grew again after some time. Similar cases 
are scattered through the literature of the subject. 

It is probable that there are other cases of neurotic origin in 
which bare patches are formed resembling, and sometimes in- 
distinguishable from, the last class, which I regard as parasitic, 
but which many dermatologists retaining the old view consider 
to be neurotic. Of these may especially be mentioned the cases 
in which leuko- and melanodermia are associated with what in 
other respects resembles ordinary alopecia areata. In some 
cases the leukodermia has preceded and in other cases followed 
the alopecia, and although the number of these cases is very 
small, perhaps one per cent., yet inasmuch as leukodermia is 
a rather rare disease, the association is more frequent than can 
be accounted for by " coincidence," and as leukodermia is uni- 
* Lci7icet, June n, 1881. 



ALOPECIA AREATA. 12 13 

versally regarded as of neurotic origin, the associated alopecia 
would then probably be of similar pathogeny. Thibierge states 
that the alopecia which may occur with leukodermia is of a 
special type, and is of bad prognosis. I have not been able to 
verify the statement. ' 

In one of my cases, a girl of seven, the baldness was said to 
have begun in patches after a fright, but was complete when 
I saw her, and of nine months' duration. There was symmetri- 
cal leukodermia of both hands and forearms, which came on 
some months after the alopecia. This child has recovered the 
greater part of her hair. 

The difficulty of coming to a conclusion in some cases is 
shown by the following instance: 

A youth of eighteen, of general good health and physique, 
had a very marked degree of seborrhea, three patches of 
alopecia areata, and leuko- and melanodermia, which had fol- 
lowed the alopecia. This case can equally well be regarded 
according to the bias of the observer as alopecia areata pro- 
duced by the seborrheic microbe of Sabouraud, or as a neurosis 
which also led to the leukodermia, or as three independent 
conditions. 

Class III. represents what may be called true Alopecia 
Areata, and is the accepted type of the disease, the previous 
forms having hitherto been mixed up with it. In opposition 
to the other groups, it might with propriety, in my opinion, be 
called alopecia parasitica. Inasmuch, however, as its pathology 
is still a moot point it is better to adhere to the generally re- 
ceived title of alopecia areata. 

It forms probably 90 per cent, or more of all the cases 
of alopecia with complete denudation of the affected part, and 
of all forms of skin disease about 2.5 per cent, in England, 1.5 
per cent, in Scotland, 3 per cent, in France, .5 to .8 per cent, in 
North and South Germany, and about .5 per cent, in America. 
In my private practice it is nearly 6 per cent., but this probably 
exaggerates its real frequency. 

Symptoms. — The disease usually commences on the scalp, or 
in males it may be on the whiskers or beard; less frequently it 
may affect any part that is normally hairy, such as the eye- 
brows, axillae, and pubes, or even the downy parts. 



1214 



DISEASES OF THE SKIN. 



There may be only one or many patches, the multiple patches 
being formed in irregular succession and arrangement, sym- 
metry being exceptional. Although there is no unilateral 
tendency, on the whole, in men, the earlier patches are more 
often situated posteriorly, just above the line of junction of the 
parietal and occipital bone, and at a corresponding level at 
the sides; this corresponds in many instances with the line of 
close contact of the head covering. The chin is also a not un- 
common position, but most frequently in those who are clean 
shaved. The shape of a patch is primarily round, though it may 
become irregular by coalescence with neighboring patches. 

When not compound the patches range from one-half to two 
inches in size, and while each is generally rapid in its forma- 




Fig. 84. — Band form of alopecia areata. 

tion at first, subsequently it may spread very slowly. There 
is no limit to the area of the compound patches, and by the 
frequent formation of new ones the whole scalp and face may 
be denuded. On the other hand the disease may be arrested at 
any point, from a single small patch upwards. 

A less frequent form is a broad band of baldness which may 
extend posteriorly from ear to ear or go all round the head 
(Fig. 84). This band or serpiginous form is much less common 
than the round patch form, and often extends much more rap- 



ALOPECIA AREATA. 



1215 



idly. In one of my cases the hair came off in zigzag channels 
until the whole scalp became denuded. This variety is the 
ophiasis of Celsus, who considered it the more favorable form, 
but this is only correct when it occurs in children; in adults, in 
my experience, the prognosis is not so good as in the ordinary 
form. 

Quite recently Sabouraud has claimed this form as ex- 
clusively a disease of childhood, and only seen in adults as a 
recurrence. This is true only for the majority of cases. I have 
seen repeated instances in which the first attack was in adult 
life. Moreover, both in children and adults it is often seen in 
association with ordinary patches and (!) stumps may also be 
present. A girl of ten contracted tinea tonsurans with scaly 
and stumpy patches ; a year and a half later her hair came out 
and she was completely bald in a month. Three years later the 
hair was completely restored, except a band one inch wide 
extending posteriorly from ear to ear. Two years after this a 
bald patch appeared just above the nape with numerous (!) 
stumps at the border. I cannot therefore acknowledge that 
there is either any essential difference between the ophiasis 
commencing in childhood and that of adult life, and there are 
so many connecting links that I could never satisfy myself that 
there is a pathogenic difference between band and patch 
alopecia. 

Sabouraud,* however, is inclined to a neurotic theory on ac- 
count of its symmetry, and because he cannot find his sebor- 
rheic micro-bacillus or other organism, but ordinary sebor- 
rhea never is seen in this position. 

The surface of the bald patch is as smooth as a billiard ball, 
whiter than normal, and whether from the loss of so many hair 
bulbs, or from atrophy of its own tissue, the scalp is obviously 
thinner than before, more lax than in health, and sometimes 
slightly depressed below the healthy skin, and while the tactile 
sensibility on the patches is inappreciably diminished, except 
perhaps with an esthesiometer,f there is much less sensitive- 

* Sabouraud appears to think he has re-discovered this variety, and 
says that it is not described by any modern authors. This may be true 
of French, but is certainly not so of English authors, from E. Wilson 
downwards. It was figured in my last edition. 

f Neumann says it may be anesthetic. 



1216 DISEASES OF THE SKIN. 

ness to irritants, the diseased area often remaining unaffected, 
while the normal skin is inflamed by the remedies applied. On 
the borders of the patch, as long as it is spreading, there are 
a few short hairs, as characteristic in their way as those of tinea 
tonsurans, and I have never met with them in the indisputably 
neurotic cases. They are generally about an eighth of an inch 
long, sometimes longer, quite straight, thicker at their free end 
than at the point of insertion, come out almost with a touch, 
and end in a point, or show a slight thickening at the end of the 
otherwise atrophied root, and look just like a note of ex- 
clamation sign (!), with or without the terminal dot (Fig. 85). 
In the early stage a few of these hairs may sometimes be seen 
in the middle of the patch, and I once saw a commencing patch 
uniformly covered with these hair stumps, but they were all 



So 




h 

a 

Fig. 85.— Short (!) hairs of alopecia areata. 
b, natural size; a, the same hair X 50; c, c, c, atrophied roots, X 50. 

gone by the following week. In some cases they are present 
in enormous numbers, and constitute what Besnier calls 
" pelade a cheveux fragiles." There is, however, no essential 
difference between these and the ordinary forms, but they indi- 
cate that the case is one of rapid extension. The thickening 
of the free end is only apparent, and represents the diameter 
of the normal shaft, which, owing to damaged nutrition, has 
broken off close to the surface, while the atrophied root is 
gradually extruded, and soon either falls out or breaks off at 
its thinnest part; hence their presence is a sign of recent ex- 
tension, and they are never present in old stationary cases. 
Another sign of active extension is that the apparently normal 
hair adjacent to the patch is very loose; a moderate pull will 
bring out many hairs at a time. 

The course of the disease is very variable. While in some 
cases the patches seem to form suddenly, whole tufts of hair 



ALOPECIA AREATA. 



12 17 



coming out when it is combed in the morning, without any 
previous symptoms, or at most slight itching, and then per- 
haps going on from bad to worse, patch after patch forming 
and running together until all hair is gone; in others it pro- 
ceeds much more slowly, taking weeks or months before the 
whole head is denuded; or, after going on for some time, the 
disease may come to an apparent termination, the hair begins 
to grow over some patches, while fresh ones are forming else- 
where, or fine, downy hair springs up after some time, only to 
fall out after a brief sojourn. In very favorable cases the dis- 
ease stops after one or two patches have appeared. A patch 
may be perfectly stationary for a long period and then begin 
to spread and fresh patches appear elsewhere. 

When the disease takes a turn for the better the hair round 
the patches can no longer be easily pulled out; then the patch 
gets smaller by the formation of new hair at its periphery, or 
in very happily circumstanced cases, or when the patches are 
small, new hair springs up uniformly all over the bald area. 
This new hair is generally very fine and pale, and lanugo-like, 
even in dark-complexioned people, and is seldom of normal 
color at first. In many it is quite white, and thus there may be 
patches of white mingled with the normal darker hair, produc- 
ing a curious piebald appearance. When the whole scalp has 
been denuded I have seen the whole of the hair return quite 
white, and after some months gradually resume its normal dark 
color. 

Eventually, unless the patient is on the wrong side of fifty, 
when the result is doubtful, the hair becomes more vigorous, 
and the pigment is restored, and it is occasionally possible to 
trace its progress. Thus at the distal extremity, or first formed 
part, both cortex and medulla are colorless; nearer the scalp 
the medulla is pigmented, but the cortex is white; while 
nearer still the whole is permeated with pigment particles (Fig. 
82). Although recovery is generally very slow, months or years 
being required for it to be complete, the partial cases, in all but 
the elderly, almost invariably get well, and a large proportion 
even of the generalized ones eventually get sometimes com- 
plete, sometimes incomplete, restoration. Relapses are fre- 
quent, either soon or only after a long interval, in about twenty 
per cent, of the cases in my experience, some of them having 



12 18 DISEASES OF THE SKIN. 

been attacked several times. In a lady of thirty-two years it 
began when she was seven years old, and she had often been 
nearly well, i. e., with only a single small patch; but she had 
never been quite free. This patient was a strong, healthy 
woman. In the unfavorable cases the scalp becomes very 
smooth and shining, and the orifices of the hair follicles are 
either obliterated or marked out only by sebaceous secretion, 
and there is often a white atrophic circle round each orifice. 

In those who wear a beard or mustache the first sign some- 
times is not baldness, but a portion turns white and may 
enlarge, the hair not falling out for some weeks or months 
afterwards. It is, however, much more frequent in those who 
are habitually shaved at a barber's, the first sign being a bald 
patch. 

Variations. — Besides the band form already mentioned there 
are cases in which one or more pea-sized bald spots appear in 
various parts of the scalp. They show very little tendency to 
enlarge, seldom attaining to more than half an inch, and the 
majority are not more than a quarter of an inch in diameter; 
their number, however, is very likely to increase, and occa- 
sionally they are very numerous. Their aspect is pearly white, 
and they are often difficult to distinguish from a scar; it is 
seldom possible to find any diseased hairs at the border, and 
very difficult to make hair grow upon them. Such a condition 
may be seen sometimes as a sequel or complication of ordinary 
ringworm, but it may also occur without any history of such 
an antecedent, either sporadically or in groups of cases in 
schools or families. It must be distinguished from the concave 
permanently bald cicatrices of alopecia cicatrisata. 

Class IV. — Alopecia Seborrhoica Circinata. For some time 
past I have observed cases in which one or more circular bald 
patches have been present in association with dense seborrheic 
scurfiness of the scalp. The denudation is complete, but the 
surface is more or less scaly like the rest. At the periphery 
of the patch may generally be found some short straight hairs, 
which do not pull out easily, and are longer than and not like 
the characteristic (!) stumps, although a few of the latter may 
be occasionally found as well. 

There is often only one patch, and seldom more than two or 



ALOPECIA AREATA. 1219 

three, and the patches are usually on the vertex, more often 
behind than in front. This variety is of interest, especially as 
lately Sabouraud has claimed that all true alopecia areata is the 
direct result of the seborrheic bacillus — a view which does not 
appear to me to be consonant with the clinical facts. The above 
variety is not very common in my experience, occurs in chil- 
dren even more often than in adults, and is usually very amena- 
ble to treatment, whereas Sabouraud's seborrheic alopecia 
areata appears to correspond nearly with my Class III. But 
he says that it never occurs until after puberty; does not attack 
the borders of the scalp, and that the stumps never have a 
brushlike termination, but are always beveled. From all these 
" nevers " I strongly dissent. Finally, his statement that the 
seborrheic micro-bacillus is present in all the cases he has exam- 
ined, I am quite willing to accept on his authority, but not the 
deductions he draws from the fact. I only accept this organism 
as one of the causes of bald patches. With regard to stump- 
ends a brushlike termination is not very uncommon, and 
Blaschko says trichorrhexis is a very frequent, if not constant, 
initial sign of alopecia areata. I should, however, say that 
a beveled end is the rule. 

Etiology. — The disease occurs in both sexes, but is said by 
some authors to be more common in females; but this is not 
true — in my experience, out of 506 hospital cases, 275 were 
males and 231 females. In my private practice the proportion 
is nearly the same. The range of age is from two to sixty, but 
only 10 out of the above cases were under five, and 21 only 
over forty-five. It is much more common in childhood; 214 
of my cases were under fifteen, 214 occurred between fifteen 
and thirty-five, 57 between thirty-five and forty-five, and 21 
after that age. These statistics show that it is not most fre- 
quently a disease of middle age, as Sabouraud states. 

It has been asserted that it occurs exclusively among dark- 
haired people. This, however, is certainly not true. I have 
repeatedly seen it among fair-haired persons of both sexes, but 
I am inclined to believe that it is more common in dark-haired 
persons. A man, aged twenty-nine, said that the disease was 
of fourteen years' duration altogether, though his hair had 
regrown several times. The mother, who has dark hair, first 
had it, then the patient, who also has dark hair, and then his 



1220 DISEASES OF THE SKIN. 

younger brother, also with dark hair. The father and sister, 
who have fair hair, have not had it. This is not a solitary in- 
stance of such a preference. It is seen in all stations of life, 
but not often in the most prosperous classes. 

The etiology of the admittedly neurotic group has been suf- 
ficiently discussed with the clinical description of each class. 
There remains, therefore, only that of Class III., or alopecia 
areata proper. In a very large proportion of cases the evidence 
is entirely negative, and satisfactory explanation of its causa- 
tion cannot even be conjectured from the history. In a small 
number there is very strong evidence of its having been com- 
municated from another sufferer from the complaint. In a 
larger number it can be shown that contagion is the probable 
cause. As an instance of direct contagion may be given the 
case of a lady of fifty, who stated that hers began soon after 
sleeping for three weeks with a married daughter who was suf- 
fering from it, who, in her turn, ascribed it to having slept with 
a lady who had been quite bald from childhood. 

Cases where contagion is probable are dependent on the pa- 
tients' statements that they have been in more or less close 
contact with others suffering from it, or that bald patches came 
on the chin soon after being shaved by a barber, or on the head 
soon after having their hair cut, especially when the tondeuse, 
or hair-clipper, has been used. Three of my patients have dated 
it as occurring soon after wearing a hired wig at amateur 
theatricals.* In a case of Feulard's it was ascribed to wearing 
a carnival mask which had previously been worn by a brother 
who had long suffered from alopecia areata. 

In a few instances I have seen it in more than one member 
of the same family, such as brother and sister, mother and child, 
father and child. 

Endemic outbreaks of bald spots, usually of very small size, 
in schools, etc., have been observed several times; one of the 

* In March, 1897, a man, set. thirty-one, came to U. C. H. with alopecia 
areata, which. had been present for a year and a half in patches. He 
stated that he had a child who was born with a fair amount of light 
hair. When five months old it began to lose its hair in patches like 
pennies. I saw the child when nine months old, and found that, although 
the hair was very thin at the temples, in the left occipital and the right 
parietal regions there were no bare spots. 



ALOPECIA AREATA. 122 1 

best known instances is that of Hillier,* in a parochial school 
of eleven hundred children of both sexes. The disease was lim- 
ited to the girls of one block from seven to fourteen years old, 
forty-three of whom were suddenly found to be affected, while 
one girl had had it for some time. The patches varied in size 
from a fourpenny-piece to an inch or more in diameter; on 
some children there was but one bald spot, on others two or 
three; most of the patches were round, but some were irregular. 
He found in the root-sheaths of two or three hairs a number 
of spores of a fungus, having all the appearance presented by 
the fungus of tinea tonsurans, and many atrophied hairs. 

A still better example, because it was investigated by a skilled 
observer in the light of recent researches, was recorded by 
Bowen of Boston, U. S. A.f In a school of sixty-nine girls 
from three to fourteen years old sixty-three were affected more 
or less. The great majority had very small, almost punctate 
lesions, but there were numerous cases with large patches of 
the ordinary type; in no instance could he find any trace of 
ringworm stumps or scales. 

The following series of my own are evidently of the same 
nature: Eight children in one family, while at the seaside, had 
each a few small, perfectly bald spots on their heads. They 
were quite bare from the first, and never larger than half an 
inch in diameter. After a time the governess, set. twenty-four, 
observed three pea-sized, oval, bare spots on her own head. 
She then went to her home, where her doctor told her it was 
alopecia areata, and not contagious. She therefore slept with 
her adult sister, who soon afterwards showed similar spots on 
her head. The mother of the children, when she came to me, 
had a bare, round spot half an inch in diameter, in the occipital 
region. It had been noticed for three weeks. The hairs round 
were loose, but there were no short hairs. 

In no case were there more than three spots, and they were 
all small. In one child there was a history of a red ring on the 
side of the cheek. Whether this small-patch variety is the same, 
or a different disease from the ordinary form of alopecia areata, 
is open to discussion. 

Many endemic outbreaks have been recorded from time to 

*Hillier's " Handbook of Skin Diseases," p. 286. 
f Brit. Jour. Der?n., vol. vi. (1894), p. 80. 



1222 DISEASES OF THE SKIN. 

time in France by Hardy, Besnier, Leloir, Dubreuilh, Feulard,* 
etc., in regiments, ascribed to the use of the " tondeuse," or 
hair-clipper, in a fire brigade in Paris, etc., and the belief in 
a contagious form of alopecia areata is firmly rooted there. In 
England Hutchinson and myself are the chief apostles of the 
creed, but our disciples are few and often half-hearted. In Ger- 
many and America the belief in contagion in one form or 
another is on the increase. Of course it is not contended that 
it is readily contagious like ringworm, only that under favorable 
circumstances it may be communicated from person to 
person. 

In a certain number of cases a relationship to tinea ton- 
surans can be demonstrated. Hutchinson believes that in 
alopecia areata in adults ringworm in childhood has been an 
antecedent. Ringworm, however, is so common a disease that 
its existence at some time prior to the alopecia areata would 
not prove much. It can, however, be shown that in those coun- 
tries, like France and England, where tinea tonsurans is most 
frequent, so also is alopecia areata. 

Instances in which adults who have been in contact with ring- 
worm have soon after developed alopecia areata are not rare, 
while in children such a sequence is comparatively common. 
Then I have repeatedly seen cases of ordinary ringworm of the 
head with characteristic bent hairs, which, after being treated 
for some time, change into smooth, bald spots with the 
straight (!) hairs of alopecia areata at the border. That smooth, 
bald spots occur ob initio which it is acknowledged are of the 
nature of ringworm, even by ardent advocates of the universal 
application of the neurotic theory, is an acknowledged fact. 
In one family, in which several were attacked, there was a 
strong reason to believe it was originally contracted from a 
horse with a ringworm. In some of this class of cases the 
patches are very small, from a hemp seed to a large pea in size, 
while in others they are of the ordinary size and aspect of 

* Feulard stated, at the Dermatological Congress of 1892, that in ten 
months, ending in May, 1892, there was an average of 3.3 out of every 
1000 men in the army affected with pelade, and the numbers were greatest 
in the great centers, and culminated in 10.6 per 1000 in Paris. A patient 
of mine, a volunteer, with typical alopecia areata, stated that during his 
month's training, nine men in his company were affected in the same 
way as himself, and attributed it to the use of a hair-clipper. 



ALOPECIA AREATA. 



1223 



alopecia areata. A lady nurse, aged thirty-five, had tinea ton- 
surans at the nape just where the hair commences. I got her 
apparently well with some difficulty, and a month or two later 
she came with a patch of alopecia areata on the temple. An- 
other lady, about thirty, came with a single patch of alopecia 
areata, which she had noticed two days. She wanted to know 
if it was ringworm, as she had recently been in contact, though 
not very closely, with a child affected with that disease. 

It may be said that these are the cases we all recognize as 
the bald form of tinea tonsurans. Without denying this I will 
only remark that they are often absolutely indistinguishable 
from alopecia areata, possessing the straight (!) hairs of that 
affection and not the bent and twisted ones of ordinary tinea 
tonsurans. Moreover, recognizable ringworm in the adult is 
infinitely more rare than the class of cases above described. 

Excluding cases of the alopecia neurotica group ninety per 
cent, of all the rest are in apparently perfect health; and of the 
other ten per cent, in my cases three per cent, only had head- 
aches and neuralgia, and in the remainder there were only com- 
plaints of trivial importance. I have, however, seen cases in 
which antecedent influenza may have had an etiological rela- 
tionship. 

The skin eruptions associated with 250 of my cases of 
alopecia areata were single instances of eruptions which could 
not be regarded as otherwise than accidental. An exception 
may be made for leuko- and melanodermia. This association 
has been noted by McCall Anderson, Thibierge, Senator, Feu- 
lard, myself, etc., and has already been discussed. 

Without denying the possibility of there being cases appar- 
ently referable to Class III., but which may be neurotic in 
origin, they are certainly few in number. 

Pathology. — This may be summed up as follows: There are 
tropho-neurotic and parasitic forms of baldness mixed up under 
the title of alopecia areata. No one would dispute that my 
first two classes are tropho-neuroses. It is also scarcely pos- 
sible to dispute that there is a parasitic form, but this, except 
in France, is only just being grudgingly admitted by many 
dermatologists. But while I believe that this form includes all 
the ordinary cases of the disease, this is not o-enerallv accepted 
yet; and the tropho-neurotic theory is still largely supported, 



I2 2 4 DISEASES OF THE SKIN. 

in spite of the fact that, if this was always a neurosis, and that, 
too, of a degenerative kind, it would be unparalleled among all 
other neuroses that it should be — first, a very common disease; 
secondly, most common in childhood and in the prime of life, 
and very rare after fifty; thirdly, most common in males; 
fourthly, the patients in a very large proportion of cases are 
strong and vigorous in every shape and way, and do not show 
any other forms of neurosis; moreover, the majority of those 
who do have other neuroses, or give evidence of a possible 
neurotic exciting cause, have only the most common forms of 
neurosis which would be found in a large proportion in almost 
any form of common diseases or ailment. Further, there is 
never a demonstrable nerve distribution, except in the small 
traumatic group of Class II. In favor of a neurotic origin is 
the fact that baldness, both diffuse and in patches, may un- 
doubtedly arise from a nerve disturbance, though the number 
of cases in which this can be proved or even rendered probable 
is very small, and in only a small minority is there corroborative 
evidence, such as concomitant migraine, neuralgia, antecedent 
influenza, worry, anxiety, leukodermia, and occasionally other 
nerve troubles. Only as regards leukodermia is there any 
strong probability that there is an etiological connection. 

I do not assert that there are no neurotic cases other than 
those of the first two classes and the leukodermic cases; but 
that, if there are such cases, they form a very small proportion, 
and it is probable that they will not show the (!) hairs which 
characterize the rest of the class which I consider represents true 
alopecia areata. 

There still remains for discussion the important point: Grant- 
ing that there is a parasite, what is the nature of the organ- 
ism? Thin, Von Sehlen, and Robinson ascribe the disease to 
a micrococcus; Vaillard and Vincent also found a coccus in an 
epidemic outbreak among soldiers. Unna describes a very 
small, plump bacillus. Sabouraud recently has come to the con- 
clusion that the same bacillus which produces seborrheic 
alopecia produces alopecia areata. The clinical difficulties in 
the unreserved acceptance of Sabouraud's theory are many and 
obvious; moreover, he expressly says that alopecia areata due 
to the seborrheic bacillus only occurs after puberty. What is 
to explain the forty per cent, of cases which occur under fifteen 



ALOPECIA AREATA. 1225 

years of age? Very few of them are ophiasis cases. Personally, 
while admitting that there are cases of bald patches in connec- 
tion with seborrhea, from clinical observation they appear to be 
in only a very moderate proportion, and many of them certainly 
occur in childhood. The strongest point in his view is that a 
filtered culture of the seborrheic bacillus injected into a rabbit 
produced total loss of hair; but he himself does not now con- 
sider this as valid evidence. This opens up possibilities that 
toxins of more than one kind will produce baldness. There is, 
however, another relationship which is equally important and 
requires investigation. 

In my original paper, and more briefly here, I have endeav- 
ored to show on clinical grounds that there is a relationship 
between alopecia areata and tinea tonsurans — a view arrived 
at independently by Hutchinson. It is worthy of notice that 
alopecia areata is most common where tinea tonsurans is most 
rife, and it is also instructive to observe that the neurotic 
theory is most strongly held in those countries, such as Ger- 
many and America, in which both scalp ringworm and alopecia 
areata are comparatively rare. In childhood the two forms of 
disease can be shown to be interchangeable, while in adults we 
only see bald patches arising either after contact with the ordi- 
nary tinea tonsurans, or from cases similar to itself. May it 
not be, therefore, that alopecia areata in adults corresponds with 
the generally admitted bald tinea tonsurans of childhood? This 
would account for the otherwise curious fact that while ring- 
worm of the head is so common in children it disappears after 
puberty; and may this not be because the hair alters in its con- 
sistence,* and the microbe is no longer able to penetrate into 
its substance, but, passing down between the root sheaths, 
separates the hair from its nutritive supply, and so leads to 
its atrophy and gradual extrusion? Or, again, it may be that 
the action of the ringworm fungus is not merely mechanical, 
and that it produces something inimical to the life of the hair 
or its papilla. That there is also atrophy, either primary or 
secondary, of the hair bulb and the tissues round, is clinically 
and microscopically evident to all, in the shrunken hair roots, 

* That there is nothing in the mere fact of adult age against the in- 
vasion of the fungus is shown in the frequency of tinea in the soft beard 
hairs of man. 



12 26 DISEASES OF THE SKIN. 

the thinned scalp, its diminished sensitiveness to irritants, 
sometimes even to touch, and the deficiency in pigment. 

Anatomy. — The anatomy of the affected scalp has been examined by 
Jamieson, Vincent Harris, myself, Robinson of New York, Giovannini, 
Unna, and others. Unna* is more in accordance with Harris and 
Robinson. 

Jamieson removed skin from the living subject in a case of two years' 
duration, and the results were entirely negative, both for tissue changes 
in or around the hair follicle, as had been described by Michelson, and 
as to the presence of a fungus. In Duckworth's case, examined by V. 
Harris, the hair follicles and sebaceous glands were atrophied, and there 



a, lanugo hair in dilated follicle; b, b, b, masses of round cells. 

was considerable increase of fibrous tissue round the follicle, and infiltra- 
tion of the outer root sheath with a new round-cell growth; the hair 
follicles were beset with nuclei, and there was an inflammatory cell in- 
filtration in the middle of the corium, extending mainly along the vessels. 
No parasite was found. My own observations were made from a patch 
which had existed five years in a man of forty. There was a scanty 
lanugo growth present here and there. Microscopically, there was 
atrophy of all parts of the hair follicles, many of which were consider- 
ably dilated, and contained only fragments of hairy substance; in others, 
the follicle was shrunken, and contained small hairs. The sebaceous 
glands (unlike Duckworth's easel appeared abnormally large, or at least 
not atrophied, and broken up into very distinct lobes by fibrous septa. 
As in his case, there was abundant round-cell infiltration of the outer 
root sheath, and all round the follicles as far down as the sweat coil, 
which was unaffected (Fig. 86). This cell growth was limited to the 

* Unna's " Histopathology " gives a critical resume to date, p. 1090. 



ALOPECIA AREATA. 



1227 



neighborhood of the follicle in the deeper part of the corium, but ex- 
tended horizontally in the papillary layer for a considerable distance 
from it. In one dilated follicle there were round, spcrelike bodies; but, 
as the orifice was quite patent, this might have been accidental. These 
observations, while they indicate the trophic changes undoubtedly pres- 
ent, may be due to pressure atrophy from the presumably inflammatory 
cell infiltration and increased fibrous tissue, and do not enable a conclu- 
sion to be formed as to the nature of the exciting cause. At the Ameri- 
can Medical Congress in 1887, Robinson of New York showed sections 
from alopecia areata which had existed only a week, and found normal 
epidermis, signs of inflammation in the corium, round-cell collection in 
the subpapillary layer, cellular infiltration with round cells, dilated 
blood-vessels, and small arteries containing fibrous coagula.* The lymph 
channels in the corium were enormously dilated, and contained also a 
fibrous coagulum. The sebaceous and sweat glands were unaffected. In 
a six months' case the changes in the papillary layer were greatest. In 
a case which had lasted several years there was atrophy of all the struc- 
tures except the vessel walls. He ascribes the sudden falling off of the 
hair to the thickening of the walls and coagula in the vessels of the 
affected area. The cause of all this he ascribes to micro-organisms, as 
described by Von Sehlen, but they were not only in the hair follicles, but 
in the lymph spaces of the corium, and consist of diplococci and cocci in 
masses, colonies, and lines, and in rows in the lymph spaces. 

S. Giovannini f has examined skin from no less than twenty cases in 
various stages. His observations show extensive perivascular infiltration 
of leukocytes, especially at the lower part of the follicle and in the circu- 
lar connective tissue layer, and thence making their way between the 
cells of the matrix and internal root sheath, and leading to degeneration 
of those cells, disappearance of pigment, and often of fracture of the 
hair shaft in the follicle. Destruction of the hair bulb, neck of the 
follicle, and internal root sheath follows, the hair falls out, and there 
is more or less atrophy of the whole follicle, and sometimes atresia of it. 
If a new hair is formed, it undergoes the same sort of regressive changes, 
and falls out before it is mature. In old-standing cases the sebaceous 
glands atrophy, and in rare cases the sweat glands undergo colloid 
transformation. According to Giovannini, therefore, the whole process 
is the result of a deep folliculitis, but he throws no light on the cause 
of the inflammation. He confirms the observations of Harris and myself 
for advanced cases, and states that the infiltration of leukocytes precedes 
the fall of the hair, but this Unna disputes. 

Diagnosis. — The diagnosis of the ordinary form of alopecia 
areata rarely presents any difficulty. The circular patches or 
bands of perfectly bald, smooth, white skin, with, at the begin- 
ning, a few short, club-shaped hair stumps at the margin, which 

* New York Med. Record, September 17, 1887, p. 402. 

-f Ann. de Derm, et de Syfih. vol. ii. (1891), p. 921, copiously illustrated. 



1228 DISEASES OF THE SKIN. 

come out easily, can scarcely be mistaken for ringworm in its 
ordinary form, in which the loss of hair is only comparative, the 
surface scaly, and the hair stumps all over the affected area 
bent, broken, and twisted, and extracted with pain and diffi- 
culty, or breaking off at the attempt. Moreover, in these 
stumps, the fungous elements are always easily demonstrable, 
while in those of alopecia areata they are never to be found 
in short hairs. 

In megalosporon ringworm the stumps are fewer and the 
baldness therefore more conspicuous, but there is rarely any 
difficulty in finding some characteristic spore-laden stumps. 
Even when the stumps are broken off short, level with the skin, 
so as to show only a dark dot, a condition sometimes seen in 
alopecia areata, the fungus is easily found in the stumps of the 
former, never in those of the latter. 

In my experience the presence of (!) hairs distinguishes the 
parasitic class from the indisputably neurotic forms. At the 
same time there is no theoretical reason why they should not 
be present, as they are only atrophied stumps. Moreover, in 
the first class, the universal distribution, the rapid development, 
and that not necessarily in patches, the frequent involvement of 
the nails, and the history of injury or mental shock, are the most 
noteworthy distinctions. In the second class the unilateral dis- 
tribution, the small number of patches, even if there is more 
than one, the absence of tendency to spread after the first week 
or two, and the antecedent injury, neuralgia, or other neuritic 
conditions, are the leading features; while in alopecia cicatri- 
sata, the smallness of the patches, the deep atrophic depressions 
compared to the slight atrophy of alopecia areata, the per- 
manence of the baldness, slowly progressive character of the 
patches, the loosened hairs with swollen root sheaths and possi- 
ble involvement of the nails, seldom leave room for doubt. 

Bald patches very like those of alopecia areata occasionally 
occur in secondary syphilis, but are easily distinguished by the 
presence of other symptoms of syphilis, and rapid recovery 
under specific treatment. 

Bald patches after prolonged exposure of the scalp to the 
Rontgen rays have also been recorded, but the baldness was 
only temporary {vide Hirsuties). 

The seborrheic class, as I have described it, is distinguishable 



ALOPECIA AREATA. 1229 

by the pronounced seborrheic scurf, and the fact that the patches 
themselves are usually somewhat scurfy, not having the 
billiard-ball smoothness of ordinary alopecia areata. 

Prognosis. — If the patient is young and the disease in patches, 
recovery may be predicted in nearly all cases, in from three 
months to two years. In persons past forty the result becomes 
less and less certain as age advances, though even then there 
is recovery in a fair number. When the disease has gone on 
until the whole scalp is bare the prognosis depends on the time 
it has been so, and on the presence of new downy hairs which 
do not fall out after a short stay. It is bad, when there has 
been no attempt at restoration after several months or years, 
if the scalp looks very smooth, the orifices of the hair follicles 
being scarcely visible, and the skin lax and atrophied; but 
restoration sometimes takes place even after total alopecia has 
existed for several years (sixteen, Michelson). 

The prognosis is very bad for most of the cases in which the 
hair has fallen out very rapidly and absolutely all over the body 
and head in the course of a week or two ; but a few recover. It 
is good for the local or neurotic form, though the hair on the 
affected area not infrequently remains white. 

It is always good for any seborrheic form. The band form 
and all patches about the nape make a tardy recovery, as com- 
pared with patches higher up. 

Treatment. — Internal remedies have very little, if any, effect. 
Arsenic, nux vomica, iron, the mineral acids, and various 
nervine tonics, have their advocates, but I have never seen any 
good that I could trace to their use. No doubt if the patient's 
health requires a tonic or other treatment, independently of the 
alopecia areata, it is wise and right to give it. On the strength 
of the restoration of the hair, in a case of myxedema, in which 
3j of the tincture of jaborandi was given three times a day for 
some time, I have tried it in several alopecia areata cases, the 
doses commencing at TI^x three times a day, and gradually in- 
creasing as tolerance was established, as at first it is apt to 
cause headache and even nausea; but I have not had any de- 
cisive evidence of its success. I have, however, thought that 
pilocarpin nitrate one-eighth to one-quarter of a grain at bed- 
time by the mouth has been of service. The patient should wear 
a flannel nightdress. As the discomfort of being in a bath of 



1230 DISEASES OF THE SKIN. 

perspiration every night is so great it should only be tried in 
cases of complete alopecia of the scalp. 

Where opportunity offers pilocarpin hypodermically injected 
into the scalp in the dose of about one-thirtieth of a grain of 
the hydrochlorate, or just enough to produce local sweating, is 
worthy of a trial. In a few of my cases it has appeared to be 
decidedly beneficial, and Morris has had a very successful case. 
Thyroid extract has not justified the recommendation it has 
received in some quarters. 

When the bald areas have ceased to extend, but the new hair 
does not grow or does so very feebly, change to a bracing air, 
such as the seaside or the mountains, or even into the country 
from a town, will often determine a more vigorous growth. 

Locally, strong stimulant applications offer the best chance, 
and all means which produce a better blood-flow through the 
scalp. One of the best is chrysarobin 5j to §j of lard, or 3ss 
to 5j of lanolin and oil, well rubbed in night and morning. This 
has seemed to be one of the best remedies in my hands; but it 
has the well-known drawback of sometimes producing ery- 
thema, with swelling of the face, even when applied only to the 
scalp; it should always be restricted to the posterior portion, 
therefore, and the patient should be warned of this possibility, 
so that he may not be alarmed at what he is apt to think is 
erysipelas. The staining of the skin and hair and of all linen 
with which it comes in contact are further drawbacks. This 
drug, being both a powerful parasiticide as well as a penetrat- 
ing stimulant, fits either theory. A cleaner and less disagree- 
able application is turpentine. The ol. pini sylvestris is the 
nicer form, one ounce with hyd. perchlor. gr. 2 or 4 dissolved 
in alcohol, while ext. capsici 5ss, or more, may be added where 
the turpentine alone exerts too little effect. It deteriorates 
after being made about a week, probably oxychlorid of mer- 
cury is formed; at all events, a white precipitate is thrown 
down, and the fluid is less stimulating. Cantharides is a fa- 
vorite application with many, either as a lotion (formulae for 
which may be seen at the end), or with a view of blistering the 
part. Blistering the patches is often useful when the disease 
has ceased to spread, and at the beginning also, at the spread- 
ing edge; it should be repeated from time to time, as the patient 
can bear it. Bulkley prefers the application of strong carbolic 



ALOPECIA AREATA. 1231 

acid; to recent and spreading patches it may be applied freely 
with wool fastened on a match, and I can bear him out that 
it acts only as a superficial escharotic; the skin is immediately 
whitened, and the epidermis peels off in a few days, but no 
sore or deep destruction ensues. I cannot say, however, that 
the beneficial results have been very striking, and I now use 
it only for quite recent small patches, and think it sometimes 
stops further extension; but if Giovannini's observations are 
correct, and there is perifollicular inflammation at a very early 
stage, it becomes a question as to whether we are not going 
on the wrong tack, and that it would be wiser to use in the 
early stage mild parasiticide applications which do not excite 
inflammation, lest we should unwittingly be adding fuel to the 
fire. I cannot, however, say that I have ever seen any harm 
ensue from the stimulating plan. Faradizing the scalp is also 
useful at the late stage, a double-tufted wire brush,* to which 
both poles are connected, being used as the electrode, and the 
scalp is brushed until the skin is well reddened. Gaiffe's and 
Thistleton's small coils are suitable instruments for the pa- 
tient's own use. 

Although shaving the scalp greatly facilitates the application 
of remedies, I am strongly opposed to it, as it necessitates wear- 
ing a wig, and the springs of this by their pressure on the scalp 
impede the circulation and greatly retard recovery, and some- 
times prevent it altogether where the springs actually press. 
There is also no advantage in keeping the hair short, and it 
makes it more difficult to conceal the bald patches. There is, 
however, a great advantage in pulling out the loose hair round 
the patch, as it much facilitates the application of remedies to 
check extension of the disease, and the patient can be assured 
that it will fall out of itself a little later. Repeated shaving 
round the patch is another means to the same end. 

Thin, acting on the parasitic theory, has revived the old prac- 
tice of rubbing in sulphur ointment, for which he claims uni- 
formly successful results, and has published fifteen consecutive 
cases so treated with recovery, the ointment to be well rubbed 
in round as well as on the patches. Sabouraud also advocates 
it. I regret to say it has not been very successful in my hands; 
3j each of sulphur, resorcin, and thymol to the §j is a formula 
* I have had a cheap form of brush made for me by Thistleton. 



I23 2 DISEASES OF THE SKIN. 

I often use. As many cases are long-continued, and improve- 
ment is at the best only slow, it is well to have alternative 
remedies. Hebra and Kaposi use the expressed oil of mace; 
liq. ammonise by itself, sponged in, or in the form of a liniment 
with equal parts of olive oil, is a good remedy, and Wilson adds 
four times as much spiritus rosmarini as ammonia. He also 
advocates equal parts of liniments of camphor, ammonia, 
chloroform, and aconite. The shampooing necessary to rub in 
these liniments has its use. Tannin, nux vomica tincture, 
pepper, oil of mustard, various mercurial preparations, veratria, 
a legion of other remedies, have their respective champions and 
testify to the obstinate character of many of the cases. The 
practice of those who believe in the universal application of the 
neurotic theory differs very little from that of others; the 
stimulating remedies are nearly all microbicide also. In all 
cases the patient should be enjoined to persevere diligently, 
however disheartening the slow progress may be. 

ALOPECIA CICATRISATA. 

Synonyms. — Cicatricial alopecia; Alopecie cicatricielle (Besnier); 
Pseudo-pelade (Brocq) ; Alopecia circumscripta seu orbicu- 
laris (Neumann). 

Definition. — An inflammatory disease of the scalp producing 
destruction of hair follicles, at first in small depressed cicatricial 
areas, which often coalesce into large irregular areas. 

Neumann was the first to describe this condition, but imper- 
fectly, as he only saw an early stage. Brocq (first in 1885) an d 
Besnier have independently described it more clearly and accu- 
rately. It is a rare disease, but a good many cases have come 
under my notice. It first attracts attention as elongated or 
round lentil- to pea-sized and larger concave (occasionally con- 
vex) bare cicatricial spots with diminished sensibility. They 
increase in number and to some degree in size, especially on the 
vertex, where they often coalesce, forming irregular elongated 
areas, into which the healthy hair projects like irregular serra- 
tions.* Small tufts of hair are also seen standing out like small 

* In many cases this is a very striking feature, and at one time, think- 
ing I had discovered a new form of disease, I labeled these cases 
" alopecia serrata." 



ALOPECIA CICATRISATA. 1233 

oases. They are apparently healthy, but when pulled they come 
out with very slight traction, and the root sheath is attached 
and swollen from the imbibition of fluid. The surface of the 
part affected is generally quite white, but sometimes pink or a 
very narrow ring of redness surrounds the most affected hairs, 
or there may be a slight powdery scaliness where the hair is 
inserted, but most of the hairs look quite normal until they are 
pulled out. There is never any suppuration at the hair follicles, 
unless Quinquaud's disease is a variant of it. The disease, unless 
arrested by treatment, goes on for many years, and ultimately 
large areas of the scalp are permanently denuded of hair, for 
there is never any restoration on the bare spot, except some- 
times at the borders of a patch. There are no (!) stumps, but 
occasionally one or two stumps may be found buried nearly 
to the end, and when extracted they are found to have no 
attachment, have no root sheath, and under the microscope the 
root-end sometimes has a concavity like the mold of the hair 
papillae. The nails are not affected, as a rule, but I have seen 
them slightly pitted, and, as in the following case, profoundly 
affected. 

A gentleman, aged thirty-five, in robust health, and with no 
history of antecedent worry, syphilis, or other serious illness, 
had a large number of bare, depressed, pea-sized spots on the 
scalp, chiefly at the vertex; the hair round them was loose, and 
came out with the sheaths attached, and there were no (!) hairs. 
All the nails of the fingers and toes underwent the following 
changes: they first separated from their bed, then became of 
a dirty yellow color, and finally thickened without splitting; 
the surface remained smooth on the finger and big toe nails, 
but in those of the smaller toes the free end was thick, yellow, 
and everted, while the proximal part was thinned, rough, and 
striated, but not discolored, a deep furrow separating the thin 
from the thick part. In a man of forty-five, who had had the 
disease six months, the bald patches were very numerous on 
the vertex and began as irregular spots. The largest com- 
pound area was as large as the palm, but narrower, and with 
tufts of hair scattered over it. Some of the bald areas were 
slightly reddened. Pernet stained some of the root sheaths for 
micro-organisms, but none were found, and this has been the 
experience of others; nevertheless there can be little doubt but 
78 



12 34. DISEASES OF THE SKIN. 

that it is a schizomycetic disease setting up a mild degree of 
inflammation which destroys the hair papilla. 

Diagnosis. — These cases are sometimes confused with alopecia 
areata, but the irregular outline of the larger patches, the tufts 
of normal-looking hair on the bald areas, the depressed cica- 
tricial surface, the absence of the (!) stumps of alopecia areata, 
and the fact that the hair is never restored, are distinguishing 
features. The swollen root sheaths suggest an inflammatory 
origin. Besnier, however, has met with two employees in the 
same firm, in whom one had alopecia areata of the beard while 
the other had pronounced cicatricial alopecia. Also the case 
of a woman with cicatricial alopecia without folliculitis, and 
shortly after in a close relation ordinary alopecia areata. Brocq 
has also seen a case which he at first thought was an alopecia 
areata, then that it was cicatricial, but the patient said the hair 
had regrown on some precisely similar patches, but not for sev- 
eral years. Both he and Besnier, therefore, have doubts whether 
the disease is a fundamentally distinct one from alopecia areata. 

The treatment I have found most successful is to pull out the 
loosened hairs and rub either a biniodid of mercury ointment 
two grains to the ounce, or one of sulphur and resorcin of each 
gr. xx to the ounce, but it takes a long time to stop the process. 
Besnier affirms that cases sometimes get well of themselves. 

ULERYTHEMA OPHRYOGENES. 

Deriv. — ov\rj, a cicatrix ; epvOr/pLa, redness ; ocppvs P the eyebrows. 

Ulerythema is a term proposed by Unna to designate affec- 
tions characterized by inflammatory redness followed by scar- 
ring (ovXrf, a cicatrix; epvOrjpia, redness). If he had succeeded 
in establishing it, it would have included lupus erythematosus, 
the so-called " lupoid sycosis," and another acneiform affection,, 
but fortunately it has only been retained for the affection de- 
scribed by Taenzer.* 

This affection was first described by Taenzer in 1885, f r c» m 
six cases, the first three in one family. It commences in earliest 
infancy by redness of the skin of the eyebrows, where it per- 
sists throughout life; later it invades the neighboring parts, 
* Monatsh.f. praki. Derm., 1885, No. 5. 



FOLLICULITIS. ^35 

principally the face, the scalp, and the nose, rarely the arm. 
At first it looks like a lichen pilaris developed on a slightly red 
base, then at some point, in severe cases, there arises a marked 
but very superficial inflammation of the skin, and its effect on 
the hair follicles is to produce in parts a slow growth of vigor- 
ous hairs, generally in tufts. One then sometimes observes the 
symptoms of a non-suppurating folliculitis, while the intermedi- 
ate skin becomes atrophic. 

The ultimate result of this slow inflammatory process in the 
only case he was able to observe, consisted in a total alopecia 
and atrophy of the scalp, analogous to that of a long-standing 
favus. Taenzer thought that the disease was not very rare, but 
that it was overlooked because it was only when it invaded the 
scalp that it produced such marked and characteristic symptoms 
as to show it was no ordinary malady. Dubreuilh considers it 
to be a keratosis pilaris, and describes the presence of minute 
hard papules, pierced by an atrophied hair. It begins on the 
outer side of the eyebrow, and advances in the course of years 
to the inner end; an atrophic scar with minute telangiectases is 
left. 

The treatment Dubreuilh recommends is cod-liver oil, iron, 
and arsenic, and good hygiene. Locally, resorcin soap and in- 
unction of five per cent, salicylic acid with glycerin; but the 
disease is very rebellious to treatment. 

FOLLICULITIS. 

Inflammation of the hair follicle — or, as it more frequently 
really is, perifolliculitis — is very common in some form or other. 
It varies greatly in degree, being sometimes clinically but little 
more than congestion, at others so severe as to produce sup- 
purative destruction of the follicle. Some of the milder forms 
of inflammation have already been discussed under the group 
of lichens, others under eczema and pityriasis rubra pilaris, 
ringworm,* and others under acne varioliformis. They are so 
diverse in their etiology, symptomatology, and pathology, and 
of many forms we know so little, that satisfactory classification 
is at present not practicable, though a very praiseworthy at- 

* Leloir's " Conglomerative Pustular Perifolliculitis" has been proved 
by Sabouraud to be due to a trichophyton. 



1236 



DISEASES OF THE SKIN. 



tempt has been made by Brocq * in this direction. Here only- 
three forms will be discussed: the common sycosis and the two 
rare affections, folliculitis decalvans and dermatitis papillaris 
capillitii. There is, however, as will be shown in discussing 
dermatitis papillaris capillitii, strong reason for believing that 
the three affections are closely related, and own a common 
origin, viz., the staphylococcus aureus and albus, the different 
clinical manifestations being probably a matter of locality for 
the most part. As this is not yet generally admitted — indeed, I 
am not aware that the theory has been advanced before, except 
as regards the two last diseases — I have still considered them 
separately. 

SYCOSIS.f 

Deriv. — 6VHG06i$, figlike, from avuov, a. fig. 

Synonyms. — Acne mentagra; Ficosis; Lichen menti; Folliculitis 
Barbae; Ulerythema sycosiforme (Unna); Fr., Sycosis non- 
parasitaire; Ger., Bartfinne. 

Definition. — Chronic primary folliculitis of the hairy parts of 
the face, especially of the beard, due to microbic infection. 

Formerly sycosis was divided into non-parasitic and parasitic 
sycosis, the latter, or tinea sycosis, representing the inflamma- 
tion excited by the trichophyton fungus. Modern research 
has, however, shown that the so-called non-parasitic form is 
also due to an organism, but belonging to the schizomycetes 
instead of to the hyphomycetes, and we have, therefore, 
schizomycetic and hyphomycetic sycosis, or, as Unna puts it, 
coccogenic and hyphogenic sycosis, to which he adds the bacil- 
logenic form of Tommasoli. Only the coccogenic form is con- 
sidered here, and this form is intended when sycosis is spoken 
of without qualification. Tinea sycosis is described with the 
other fungous diseases. 

Sycosis is not a common disease, one in three hundred being 
the proportion according to Hebra, but in my experience one 

* Second edition, 1892; " Folliculites et Perifolliculites," p. 283. 
•f- Author's Atlas, Plate LXXXVIII., Figs. 2 and 3, represent a mild 
form affecting the whisker and a similar condition of the eyebrow. 



SYCOSIS. 



1237 



in one hundred and fifty is nearer the mark. The name is con- 
ventionally limited to primary folliculitis of the beard, whiskers, 
or mustache; but it may also attack the eyebrows, the lashes, 
or vibrissas of the nose; and a precisely similar inflammation 
may occur in the coarse hairs of the axillae and pubes of both 
sexes; on the scalp, however, folliculitis is generally secondary 
to an eczematous inflammation, which clears up in the skin 
between the follicles, leaving them still inflamed, but sometimes 
an ordinary coccogenic sycosis extends directly from the whis- 
kers, and I have seen it over the whole vertex in a seborrhei- 
cally bald man, but not extending beyond the seborrheic region, 
and attacking the fine regrowth of the seborrhea and not the 
more vigorous sidegrowth. 

Symptoms. — Sycosis varies greatly in extent and severity. 
Papules, nodules, or pustules may be present, and each is 
traversed by a hair or hairs in the center. Beginning com- 
monly in the beard, acneiform, hemispherical papules or nodules, 
soon developing into pustules, form round the hairs. At first 
only few and isolated they gradually increase in number and 
aggregation; and while, on the one hand, the disease may be 
limited to a single patch, in other cases, by the junction of 
multiple foci and peripheral accretion, wide areas are involved. 
There is, however, much less tendency to the multiplication of 
foci in this than in hyphogenic sycosis, the extension taking 
place, in the main, peripherally. 

The hairs are at first firmly seated, are pulled out with pain 
and difficulty, and even in the papular stage the root sheaths, 
on removal, are seen to be swollen by serum imbibition quite 
down to the end. As the suppuration becomes more free they 
are loosened and easily removed. In cases of moderate severity 
the pus may dry into closely adherent, thin, brown or yellow 
crusts, each spitted, so to speak, by its central hair; while in 
severe cases the pustules are so quickly crowded that they 
colesce into infiltrations, which may fungate,* and are covered 
with purulent crusts. When these are removed the hairs are 
left standing in shallow pits produced by the loss of their root 
sheaths, or when the process goes a little further the follicle 

♦It is this condition that first earned for it the name of sycosis, from 
its resemblance to the inside of a fig. It is more common in the tinea 
form. 



I23 8 DISEASES OF THE SKIN. 

is destroyed, the hair falls out, and cicatrization and permanent 
loss of hair ensue. If untreated the process invades fresh folli- 
cles, until the whole of the hairy part of the face is affected, but 
it never travels on to the glabrous skin. In severe cases it may 
reach all over in weeks or months; in others of less intensity 
the whole extent is not traveled over for a long time, the process 
sometimes lasting, with remissions and exacerbations, from ten 
to thirty years. In these chronic cases there is a general infil- 
tration and redness, partially covered with small white scales, 
with a varying number of pustules interspersed, according to 
whether there is a remission in, or renewal of, the activity of 
the inflammation. There is then always more or less scarring 
from previous attacks, and occasionally keloid ensues in the 
cicatrices. 

Besides the lesions that have been described swellings the 
size of a pea to a finger-nail are often seen here and there. 
They are soft and fluctuating, and when the hairs in them are 
removed, give exit to pus by the numerous openings produced 
by the epilation. The hairs may also come out spontaneously 
previously to the nodule breaking down. Even when the dis- 
ease is apparently cured relapses are frequent, especially when 
the beard has been allowed to grow too soon. 

Variations. — In old-standing cases the intensity of the inflam- 
mation sometimes subsides, and there is only left a chronic, red 
patch more or less covered with white scales and an occasional 
pustule from time to time. At the commencement of the dis- 
ease also mild cases of this type may be sometimes seen, but 
usually the pustules are more numerous. As will be described 
under the pathology two different organisms may produce sim- 
ilar eruptions of this mild type. 

Milton more than thirty years ago applied the term lupoid 
sycosis to a variety of scar-leaving folliculitis, which generallv 
begins at the upper part of the whiskers and slowly travels 
downwards with a narrow erythematous margin, with marked 
infiltration, followed by cicatricial atrophy and destruction of 
the hair follicles. The lesions may be papular, vesicular, or 
pustular, or when the intensity of the inflammation has sub- 
sided, only erythematous and scaly, with more or less infiltra- 
tion. After a time the process comes to a standstill on one side, 
but may start again on the others. Brocq, evidently unaware 



SYCOSIS. 1239 

of Milton's meager description, has described a similar condi- 
tion as sycosis lupoide, and Unna as ulerythema sycosi forme. 
Unna lays stress on the primary vesicular character of the affec- 
tion, the sharp limitation of the interfollicular erythema from 
the healthy parts, and the superficiality, chronicity, and rebel- 
liousness of the inflammation and the final patchy character of 
the scar formation, as distinguishing characters from ordinary 
sycosis. 

Etiology. — The disease being limited to the beard and whis- 
kers, obviously only adult males are liable to it, but the 
analogous folliculitis of other regions may occur in adults of 
both sexes; but it is never so obstinate as in the face. It is 
common on the upper lip in those who are subject to nasal 
catarrh, doubtless from pus contamination. Brooke contends 
that it is contagious, and frequently conveyed by the shaving 
brush, especially by those barbers who have to do with the un- 
washed classes. My own impression is that it is certainly more 
frequent in those who allow the beard to grow than in those 
who shave, and I agree with Brooke that it may be communi- 
cated by barbers, but more frequently they convey a tinea 
sycosis, which in mild forms is very common in my opinion, 
the idea that it is rare having arisen from restricting the term 
to the more severe kerion forms of it. In most cases impetigo 
contagiosa only is conveyed, but if this is not cured soon the pus 
cocci get into the follicles and produce sycosis. 

Pathology. — The disease, as already stated, is an inflammation 
in and around the follicles. The way in which it spreads from 
follicle to follicle suggests the presence of a micro-organism, 
but Bockhart was the first to demonstrate that pus cocci 
(staphylococcus aureus et albus), by their presence in and 
round the follicles, could and did excite a sycosis of the char- 
acters described; henCe the appropriateness of Unna's name, 
coccogenic, as opposed to hyphogenic (tinea) sycosis. Tom- 
masoli has also obtained a special organism, which he and Unna 
have called bacillus sycosiferus fcetidus, in a case which appeared 
to be ordinary coccogenic sycosis of mild type. Tommasoli 
proved his point by obtaining typical sycosis by inoculating pure 
cultures on his own skin and that of rabbits. 

The anatomy has been investigated by Wertheim, who 
showed that each follicle was converted into a small abscess, 



i2 4 o DISEASES OF THE SKIN. 

and Robinson * of New York examined skin from the living 
subject, and found that primarily the inflammation was peri- 
follicular, exactly like other vascular connective tissue inflam- 
mations. Thence serum and even the other products of inflam- 
mation penetrate the follicle, whose cell elements swell and dis- 
integrate. The pus infiltration is greatest at the fundus, de- 
creasing from thence upwards. The papilla is comparatively 
seldom destroyed. Pus reaches the surface by breaking through 
the epidermis round the follicle; and when the hair is pulled out 
the whole cavity is seen to be lined with pus cells. The sebace- 
ous glands are affected after the hair follicle, while the sweat 
glands are only occasionally involved. 

Unnaf gives a long description of the process too elaborate 
for quotation. He describes four stages, two superficial and 
two infiltrating. The first is an impetigo of the neck of the 
follicle; the second is a nodular perifolliculitis of the follicle- 
neck, consisting of an inflammatory, firm, painful nodule; the 
third is that of perifollicular abscess, but affecting at first only 
the side of the follicle. Up to the fourth stage restitution is 
possible, but in this final stage of follicular abscess there is sup- 
puration of the whole follicle, with consequent loss of hair and 
the production of a scar. 

Diagnosis. — A chronic inflammatory disease, limited to the 
hairy region of the face, and beginning in the follicles, can only 
be sycosis. The diseases most like it are eczema, tinea sycosis, 
and tertiary syphilis. 

Eczema resembles the slighter and more chronic cases of 
sycosis, but may be distinguished by the following points. The 
inflammation is seldom exclusively in the hairy region in eczema 
throughout the whole course, though it may be so. When it 
comes first under observation a history or evidence of inflamma- 
tion in the neighborhood is generally obtainable. The inflam- 
mation does not begin in the follicles, but in all parts of the 
cutis, and, at first, is more superficial than sycosis. This may 
be shown by pulling out a few hairs, when in some of them the 
root sheath is only swollen by serum imbibition at its upper 
part, while in sycosis it is always swollen to the end. The in- 
flammation also seldom approaches in intensity that of severe 

* New York Med. Jour., August and September, 1877. 
f " Histopathology," p. 373. 



SYCOSIS. 1 24 1 

sycosis. When an eczema of these parts has lasted some time 
the inflammation clears up between the follicles, leaving them 
still inflamed. The two conditions then become indistinguisha- 
ble, except that the history may show that this eczematous fol- 
liculitis is secondary to a more general inflammation, but the 
distinction at this stage is of no practical importance, as the 
local treatment would be the same. 

Between sycosis and tinea sycosis the points of difference are : 
the tinea is more acute in its development, and frequently be- 
gins with a circinate, circumscribed, scaly patch, but subse- 
quently the suppuration is very free; the affected part is lumpy 
from the numerous pustules and nodules; the hairs pull out 
easily and without pain, and their nutrition is affected early, so 
that they are brittle, dull, and even bent or twisted; multiple foci 
are much more common, and are seldom seen in the coccogenic 
form except in old cases. Such conditions should lead to mi- 
croscopic examination, when the fungus can be discovered. 
Severe forms are much rarer than its coccogenic prototype, 
but slight degrees are more common. 

Ulcerating tertiary syphilids may resemble severe sycosis. 
When the crusts are removed — and diagnosis without this is 
always liable to error — the ulceration is apparent and gen- 
erally circinate in outline. The inflammation is not simply fol- 
licular, and evidence of past or present specific lesions elsewhere 
can generally be obtained. 

The symptoms considered by Unna to differentiate lupoid 
sycosis or ulerythema sycosiforme have been given under that 
form of the disease. 

Prognosis. — Sycosis is never dangerous, but often very obsti- 
nate and liable to recur. A guarded opinion as to bona-Ude 
cure in old-standing cases should always be given, but con- 
siderable improvement can always be promised. 

Treatment. — Internal treatment is advocated by some authors, 
chiefly tonics, cod-liver oil, the mineral acids, and strychnia; 
and Tilbury Fox thought highly of Donovan's solution where 
there was much infiltration. For my own part I regard sycosis 
as a local affection, in which local treatment is all that is 
necessary. 

Shaving and epilation are most important preliminary meas- 
ures, and if not practiced, either from the unwillingness of the 



1242 DISEASES OF THE SKIN. 

patient to part with his beard, or other reason, the treatment 
will be much less effective and more prolonged. Although the 
patient at first shrinks from the idea of shaving over such a 
sore surface, in moderate cases, if the hairs be first closely 
clipped, the crusts softened with pledgets of lint dipped in olive 
oil before removal, a skillful barber gives very little pain, and 
after the first time the patient does not mind it. In severe cases 
it is not necessary to shave over the worst part, as the hairs 
are loosened and can easily be pulled out; but in the moderate 
cases, after shaving, the hairs on the inflamed part may be 
allowed to grow for a day or two, and then they should be sys- 
tematically epilated, clearing a quarter to half a square inch 
daily; but the process is undoubtedly painful. Not only should 
shaving be kept up during the treatment, but continued for at 
least twelve months after apparent cure or recurrence is proba- 
ble. In very acute cases, after the part has been cleaned, sooth- 
ing applications, such as the glycerin of the subacetate of lead 
i in io, should be continuously applied on lint covered with 
oiled silk; io to 20 drops of carbolic acid to each ounce may 
sometimes be added with advantage; or an ointment of iodo- 
form gr. 5 to §j ; or europhen gr. 5 to gr. 10 may be substituted. 
Afterwards, or in cases of less severity, the applications that 
suit most cases are one or two per cent, of oleate of mercury; 
a weak sulphur ointment, about ©j to the §j ; or the diluted 
nitrate of mercury ointment: one or other of these is generally 
successful. Shaving with the Krankenheil Spring soap No. 3, 
or Calvert's carbolic shaving stick, and leaving the lather on at 
night, is a useful adjunct. 

Whatever treatment is adopted, perseverance, with unremit- 
ting care, for a long period, is essential for a complete cure. 
The more heroic method recommended by Veiel of Cannstadt 
and other German authors — c. g., Wilkinson's ointment (He- 
bra) — will rarely be submitted to in this country. Where there 
is much infiltration, as in very chronic cases, a small area at 
a time may be painted with liquor potassse and washed off in 
half a minute and a zinc ointment applied. This is sometimes 
very effectual, but in the cases of long standing the best treat- 
ment is to put the patient under an anaesthetic and thoroughly 
scarify the whole diseased surface, then rub iodoform or one 
of its substitutes into the cuts, and after the bleeding has 



DERMATITIS PAPILLARIS CAPILLITII. 1243 

stopped dress it with iodovaselin or boric acid ointment. Many 
months of tedious treatment may be saved and a better result 
obtained by this method. 

Ehrmann's treatment is worth mentioning, on account of its 
ingenuity. He introduced pyoktanin into the diseased follicles 
by cataphoresis. The anode is soaked in a ten per cent, solu- 
tion of methyl blue, then applied to the diseased surface, the 
kathode being held in the hand. Twenty milliamperes was the 
strength of the current employed. The blue coloration of the 
hair follicles is a drawback, but the same method might be 
used for other medicaments. The most recent treatment is 
exposure to the Rontgen rays until the diseased hairs fall out; 
ten minutes' exposure of about three amperes with a six-inch 
tube at about six inches from the kathode. Ten or a dozen 
exposures are generally required. 



DERMATITIS PAPILLARIS CAPILLITII. 

Synonyms. — Acne keloid or Acne cheloidique (Bazin); Sycosis 
nuchse necrotisans (Ehrmann); Sycosis papillomateux and 
Sycosis frambcesiformis (Hebra); Ger., Nackenkeloid. 

This disease is only placed here until its nosological position 
is better known. 

Under this lengthy name Kaposi * described a very rare dis- 
ease, which he said is not a sycosis frambcesiformis,! as Hebra 
thought it to be, as it does not commence in the follicles, and 
has nothing to do with syphilis, but is an idiopathic inflamma- 
tory process, commencing on the hairy border on the back of 
the neck, and spreading upwards towards the vertex, to which 
it was confined in one case. My own observations, however, 
lead me to believe that Hebra was right in regarding it as a 
hair folliculitis. 

Symptoms. — It begins as pin's-head-sized papules, at first 
isolated, but soon becoming thickly crowded together, and de- 
veloping in the occipital region into enormously vascular papil- 

* Kaposi, 2d ed., p. 485, and his Atlas of Skin Syphilis, Part III., Plate 
LXVI. 

f Hebra's Atlas, Heft, x., Tafel 3, Fig. 1. 



1244 DISEASES OF THE SKIN. 

lomatous vegetations, two or three centimeters high, and made 
up of granulation tissue. They are crusted, bleed easily, and 
exude from between the papillae a stinking secretion, while here 
and there, by the formation of intercurrent subcutaneous ab- 
scesses, they are partially undermined and destroyed. In the 
course of years they shrink, changing into a sclerotic con- 
nective tissue, and finally there is extensive atrophy of the hair 
follicles and baldness in some parts, and in others, tufts of hair 
projecting through the hypertrophied scar tissue (acne keloid). 
It is only in this final stage that cases have hitherto been re- 
corded in this country, by Morrant Baker,* Roger Williams,f 
Eve, J and two cases have come under my own observation, as 
mentioned under keloid; probably this is always the outcome of 
antecedent pustular lesions. According to the man's state- 
ment, my first case was a sequel of boils. In my second case a 
tuft of hair pulled from the middle of the tumor, where there 
was sign of inflammation, was bathed in pus. 

In 1897 I saw a man, set. twenty, whose mother said he had 
had an eruption on the back of the head and neck as long as 
she could remember. When seen there was a patch in the 
occipital region, three and a half inches by two and a half, quite 
bare and cicatricial in the center; at the border for half an 
inch all round, extending into the hairy margin, was a folliculitis 
scabbed and pustular; each pustule was from a pin's head to 
a millet seed in size, with a hair in the center, and situated on 
a slightly raised red inflammatory base. There were a few 
scattered pustules for an inch or more beyond the patch. 
There was an indurated scar, half an inch by a quarter of an 
inch, in the right parietal region. At the nape, all along the 
hairy margin, there was an irregular band of disease, due to 
the same morbid process, but the inflammation was less acute, 
and there was evidently fibrous keloidal thickening round the 
hair follicles — in short, a developing " acne keloid." Above the 
band, but joining it, was a keloidal patch an inch in diameter 
with small tufts of hair coming out between the lobes of the 
growth, but there was still some slight crusting. Below the 

* Path. Trans., vol. xxxiii. p. 367, with colored plate, 
t Williams' case is in vol. xxxv. (1884), p. 397, with histological plate. 
%Illus. Med. News, June 8, 1889, with colored plate. Fox and Heitz- 
mann in America have also met with acne keloid. 



DERMATITIS PAPILLARIS CAPILLITII. 1245 

band there was superficial scarring on the neck from destroyed 
hair follicles. 

I have related this case in some detail because it illustrates 
two points. The occipital patch corresponds closely with the 
condition described by Quinquaud as " folliculitis decalvans," 
while the nape patches showed that " acne keloid " does de- 
velop from a pustular folliculitis, and although there was no 
frambesiform condition, that is admittedly not an essential fea- 
ture. On the other hand it is an occasional feature in sycosis 
of the beard; and, indeed, Melle records a case from De Amicis' 
clinic in which an acne keloid was located in the submaxillary 
region. He also mentions cases extending to the occiput and 
vertex; according to him, also, it may affect any hairy part 
of the face. Ehrmann * has shown that in the nuchal affection 
the staphylococcus aureus and albus are probably the cause 
of the affection just as they are of coccogenic sycosis. 

Kaposi identifies this disease with Alibert's pian ruboide, f 
the case figured being that of a previously healthy young man 
in whom pustules suddenly appeared on the upper lip and ver- 
tex. Others soon followed, itched intensely, and either spon- 
taneously or from scratching the affection spread rapidly all 
over the scalp, both lips, the ears, pubes, and genitals. There 
was profuse and offensive otorrhea and rhinonhea; the scalp 
was swollen and covered with fungating, frambesiform vegeta- 
tions, with sanious fetid discharge; and the patient died in six 
months from marasmus and colliquative diarrhea. Post- 
mortem the viscera were healthy, but there were large tumors 
on the sides of the larynx, and also on the palate and nasal 
fossae. Alibert considers his case an extreme case of yaws, 
and although that view is not tenable, it certainly does not, in 
my opinion, quite accord with Kaposi's description of his dis- 
ease, which is apparently limited to the hairy scalp, and does not 
appear to be dangerous to life. An interesting case of this 
class is one reported by Hervouet J of Nantes, which began on 
the back of the vertex following a traumatism. In Payne's § 

* Archiv f. Derm u. Syph. y Bd. xxxii., September, 1895. 

f Atlas. 1814, Plate XXXV., case described p. 156, and post mortem, p. 
164. Rayer copies a portion of this plate into his own Atlas, under the 
title of " Sycosis Capillitii." 

%Ann. de Derm, et de Sy^p/i., vol. iv. (1883), p. 421. 

§ Brit. Jour. Derm., vol. xi. (1899), p. 36. 



I 



1246 DISEASES OF THE SKIN. 

case there was a frambesiform patch in the middle of the scalp 
resembling the above cases in some respects, but it recurred 
after excision, which throws doubt on its nature. 

Treatment. — In the tumor stage excision is the only plan 
likely to be successful, and there is not the same tendency to 
recur as in most keloids. But in the granulomatous folliculitis 
stage I have found the best plan is erasion with a curette, the 
granulation tissue, fibrous thickening, or pustules being thor- 
oughly scraped away, and the surface disinfected with iodoform 
or strong carbolic acid. Boric acid ointment is a good subse- 
quent dressing. The case of the young man related above was 
successfully treated in this way. Ehrmann cured his case by 
electrolysis of the diseased hair follicles, but this would be 
very tedious treatment. The Rontgen rays would be pref- 
erable. 



FOLLICULITIS DECALVANS. 

Quinquaud * has described a chronic folliculitis of the hairy 
parts, especially of the scalp, which leads to a cicatricial 
alopecia. Lailler and his pupil Robert f have independently 
described the same affection under the title " acne decalvante." 
Cases of this kind have been hitherto confounded with alopecia 
areata, Quinquaud says, but this could only be with the cases 
I have described as " alopecia cicatrisata," and in this there 
is no pustular or papular folliculitis at the border. 

The patches are about the size of a shilling, irregular in out- 
line, and almost smooth and polished, but with some granular 
points at the periphery, and red points on the white, atrophied, 
cicatricially depressed surface. At the periphery are folliculitic 
lesions, pustular, papular, or simply erythematous. Histologi- 
cally the changes were chiefly perifollicular, and, besides pus 
cocci, others in pairs and fours were found which Quinquaud 
regarded as special. The treatment Quinquaud recommends 
is to wash the head thoroughly, then for ten days paint tincture 
of iodin on and round the patches, and apply every morning a 
lotion of perchlorid of mercury gr. I, biniodid of mercury 
gr. 1-6, alcohol 3j, distilled water gj. This is of course 

* Musee, Hopital St. Louis, Moulage 1293. 

f " These de Paris," Steinheil, 1889, with photograph. 



DEPILATING FOLLICULITIS OF THE LIMBS. 1247 

to stop the disease from spreading. The hair cannot be 
restored. 

The disease appears to be intermediate in degree of inflam- 
mation between alopecia cicatrisata and dermatitis papillaris 
capillitii, but it is to the latter that I should attach it. 

DEPILATING FOLLICULITIS OF THE LIMBS. 

Arnozan in 1892 first published two cases of this affection, 
and Dubreuilh, in adding two other cases, has confirmed his 
observations. 

In the above cases it was limited to the legs, knees, and 
thighs, chiefly the anterior and lower part of the latter, and 
with an exact symmetry. 

The elementary lesion is a red papule from a millet seed to 
a pea in size, pierced by a hair in the center and sometimes 
surmounted by a pustule or crust. After several weeks the 
papule is slowly absorbed, replaced by a lenticular macule, at 
first violet red, then brown; the hair falls, and only a puncti- 
form pigmented cicatrix is left. 

These papules are aggregated into small plaques, which ex- 
tend peripherally until they attain to patches several inches in 
diameter, bounded by an irregular zone of folliculitis in process 
of evolution. This zone is ill defined owing to the presence of 
isolated papules in the healthy skin on the outside, and on the 
inner side by isolated hairs attacked at a later period than the 
rest. Wherever the process has extended the part is deprived 
of hair and punctiformly scarred and pigmented. 

The disease extends very slowly, is attended by very little 
discomfort, and may last for years. The patients have been 
middle-aged or elderly men without anything to suggest a 
cause for the malady. Dubreuilh examined two papules his- 
tologically, and found an embryonic infiltration compact and 
circumscribed, closely investing the hair follicles, and contain- 
ing numerous giant cells. The follicle is reduced to an epithelial 
cord, and the neighboring derma is filled with mast cells, but 
has scarcely any signs of inflammation. Dubreuilh could not 
find any microbe in the lesions. 

Hitherto its course has not been much influenced by 
treatment. 



1248 DISEASES OF THE SKIN. 

Folliculitis necrotica appears to be a very similar condition, 
affecting the trunk from the nape to the waist. Eddowes * has 
recorded a well-marked case. It is attended with a great deal 
of irritation. 

TUBERCULOUS FOLLICULITIS. 

Hallopeau,f Du Castel, and Feulard have described cases 
which they consider are due to tubercular toxins. They may 
be isolated or aggregated into patches, and may be considered 
as varieties of acne cachecticorum and scrofulosorum. They 
are frequently associated with lichen scrofulosorum, and al- 
most constantly with other tuberculous manifestations. They 
may form round tuberculous gummata, and even be the 
starting-point of a lupus vulgaris. They have been produced 
by the old tuberculin injections. These forms of folliculitis are 
generally situated on the trunk and limbs, especially on the 
lower limbs. 

They occur as papulo-pustules from a millet to a hemp seed 
in size, the reddened base extending beyond the moist apex, and 
sometimes there is a hemorrhagic areola (cachectic acne). 
They may in rare instances be aggregated into indurated 
patches in which the component elements are fused. They ex- 
tend by the development of new pustules at the periphery, which 
form superficial ulcerations, or there may be pemphigoid bullae 
at the spreading border. Another mode of extension is a raised 
border, which extends externally and subsides pari passu in- 
ternally, and this so rapidly that it extends all over the back 
of the leg in a few weeks. 

Histologically, Darier and Lafnte only found the signs of a 
perifolliculitis, and regarded it, therefore, as a toxic process 
round the pilo-sebaceous apparatus. 

D.— DISEASES OF THE NAILS.% 

The morbid changes observed in the nail substance are, ex- 
cept in the case of parasitic invasion, when the matrix is only 

* Shown at the Dermatological Society of Great Britain and Ireland, 
Brit. Jour. Derm., vol. xi. (1899), p. 168. 

f The original references are in Inter?iat. Cong, of Derm. Trans., 1898, 
P- 413- 

% Literature. — Author's Atlas, Plate XC, thirteen figures. Sydenham 



DISEASES OF THE NAILS. 



1249 



secondarily affected, the direct or indirect result of diseased 
conditions of the matrix, which is subject to the same patho- 
logical conditions as the other tissues, such as inflammation, 
acute or chronic, and trophic changes generally. The nail sub- 
stance, as a consequence, may undergo increase in quantity, 




Fig. 87. — Longitudinal section through the nail, and nail fold of a child 

of three years old (Unna). X 20. 

n, nail plate; k, k, granular layer of roof of nail fold; ep, eponychium. 

hyperplasia or hypertrophy, diminution, aplasia or atrophy, and 
the shape, color, and texture may be altered. 

Symptomatology. — It will be convenient to explain here the 
various terms which are used in the description of abnormali- 
ties of the nails, irrespective of their origin. 

Pterygium (7trepv^ ? a wing) means the adherence and growth 
over the nail of the fold of skin which normally exists in a 
slight degree where the proximal end of the nail joins the fin- 
ger. Retraction of this fold and exposure of the nail root 

Society's Atlas, Plate XVII. Hutchinson's Archives, vol. x., 1899, con- 
tains a large number of plates of nail diseases. Shoemaker, " Disease of 
the Nail "; a large number of abstracts and references to interesting cases, 
Amer. Jour. Citt. and Gen.-Ur. Dis., vol. viii., 1890. Hutchinson's 
Archives, vol. ii. (1891), p. 237. Also Heller, " Die Krankheiten der 
Nagel," igoo, an exhaustive monograph on the nails, with numerous 
references and illustrations. Also Pernet, " Affections of the NaiK" 
Encyclopedia Medica, vol. viii., 1901, gives copious bibliography. 

79 



1250 



DISEASES OF THE SKIN. 



occurs sometimes (Ficus unguium). It is said that curriers are 
liable to it. 



Onychia {pvvB,, the nail) is the term used for inflammation of 
the matrix, whether idiopathic, traumatic, syphilitic, or other- 
wise secondary. It is not generally applied to chronic inflam- 
mations. Typical onychia maligna is usually single, often asso- 
ciated with ophthalmia tarsi and other signs of struma, and, 
according to E. v. Meyer, is due to direct tubercular infection 
on some injury, often very slight. A more chronic and less 
severe form may be occasionally met with. In a patient of 
mine, a woman, set. forty-seven, subject to rheumatism, but 
otherwise well, suppurative inflammation of the matrix had at- 
tacked one finger after another, first of the right hand, and was 




Fig. 88. — Transverse section of a nail, made through the proper bed of 
the nail (Biesiadecki). 

a t nail; b, loose horny layer beneath it; c, mucous layer; d, transversely 
divided nail ridges, with injected blood-vessels; e, nail fold destitute 
of papillae; /, the horny layer of the nail fold which has been 
deposited upon the nail; g, papillae of the skin of the back of the 
finger. 

beginning in the left ring-finger; after being bad for eight 
months, the first attacked, that of the right little finger, healed. 
In another, a lady of thirty-one,* suppuration under the nail 
fold had attacked different nails for seven months. In one 
attack all the nails were involved together. Half-grain., doses 
three times a day of sulphid of calcium controlled it, but the 
disease recurred in a few days if she left it off. She had good 
general health, and no cause for the disease was discovered. 
* Private Notes, L. 237. 



DISEASES OF THE NAILS. 125 1 

In the more acute onychia maligna the inflammation is often 
phlegmonous, and then there is intense redness over the base 
of the nail, going on to lividity, heat, and throbbing pain; the 
nail itself is discolored by the inflammatory effusion beneath 
it; suppuration ensues, with sanious discharge; the nail is lifted 
from its bed, becoming thickened, opaque, and discolored, and 
is often completely thrown off, exposing a sloughy, easily 
bleeding surface. This may gradually clear up and heal, and 
an imperfect nail replace the old, or the inflammation may spread 
to adjacent tissues, and eventually to the lymphatics, and the 
condition known as paronychia, or whitlow, in its worst form 
be produced. It is one of the most striking symptoms of Mor- 
van's disease. 

A patient of mine had recurrent painful whitlows on nearly 
all her fingers for over forty years, the terminal phalanges were 
shortened and the ends much thickened. She had no symptoms 
of syringomyelia nor other disease. Avulsion of the nails and 
the application of iodoform produced much improvement and 
the cure of some of the lesions. The various forms of paro- 
nychia are described in all surgical manuals, and only the variety 
produced by ingrowing toe-nail will be here alluded to. This 
is produced by a spontaneous growth of the nail into the tissues, 
or, more frequently, by pressure or injury. Inflammation ensues 
at one or other upper angle of the nail, and a tender, granulat- 
ing, discharging surface is produced, which grows over the nail, 
and may go on for an indefinite time, unless suitably treated. 
The inner angle of the big toe is the usual position for this 
troublesome affection. 

Onychauxis (orv^ and av^co, to grow) is synonymous with 
increased growth, or hypertrophy, of the nail whether simple 
or, as generally happens, with alteration in texture, color, and 
shape. When the growth is chiefly forward the nail is apt to 
become bent and twisted, sometimes spirally, like a ram's horn. 
This condition is termed onychogryphosis(o^^<^and ypv7to<S, 
curved). The nail is much thickened, strongly ridged both 
transversely and longitudinally, shining, but more or less dis- 
colored, of a yellow or brownish hue. Underneath there is an 
accumulation of softened, often evil-smelling epithelium. It is 
generally limited to the toes, especially the great toe, and is 



1252 DISEASES OF THE SKIN, 

rarely seen on the fingers. Nails of this kind may be three 
inches or more long, and of great thickness. But according 
to Heller's * observations the nail itself is not much thickened, 
but there is growth of a horny mass underneath it, which does 
not contain onychin and stains blue with Gram's method, while 
true nail cells do not. In the spaces are bodies which stain 
faintly with carmalum. In slightly marked cases the nail plate 
is more thickened than in extreme cases. 

Onychomycosis {pvvB, and pivHrjS, a fungus) is the term used 
when the nail substance is invaded by a fungus. One or more 
nails may be attacked, and the fungus is that of tinea favosa 
or trichophytina. In this case the matrix is only involved sec- 
ondarily, by direct extension (see Hyphomycetic Diseases). 

There can be little doubt that the schizomycetes play a still 
more important pathogenic role than the hyphomycetes, but at 
present very little is known about the subject. 

Shedding the Nails occurs from many causes, chiefly of a 
neurotic character. They may all be shed, or only those of cer- 
tain fingers and toes. The great toe is the one most frequently 
affected. Shedding of the nails also occurs in the universal 
neurotic form of alopecia areata, in syphilis, in enteric fever, 
in diabetes mellitus; sometimes, without apparent cause; and 
Falcone f of Naples records a case of severe hysteria in which 
the nails were shed, preceded by tingling and suppuration of 
the matrix. Brown-Sequard records a case after section of the 
sciatic nerve. Shedding of the great toe-nail occurs sometimes 
in the course of locomotor ataxy, in some cases preceded by 
subungual ecchymosis. 

It occurs in cases of annual " keratolysis," as in Stone's ac- 
quired case. Acute inflammation of the skin of the hand is 
sometimes followed by shedding of the nails, as in pemphigus 
foliaceus, pityriasis rubra, and recurrent desquamative scar- 
latiniform erythema, less frequently scarlatina itself. In a case 
under Colcott Fox, I a washerwoman, set. fifty-four, all the 

* Heller, loc. cit., p. 269. 

f Deutsch. med. Wockensck., October 14, 1886; quoted in Lancet, 
October 30, 1886. 

^Colcott Fox, Brit. /our. Derm., vol. vii. (1895), p. 389. A similar, but 
more painful case was described by Rist, Annates de Derm, et de Syph., 
vol. ix. (1898), p. 1132. 



DISEASES OF THE XAILS. 1253 

terminal phalanges of the fingers and toes were inflamed, and 
the nails were shed without alteration in texture. 

In a severe case of impetigo herpetiformis of Jamieson, the 
nails were shed and replaced by soft yellow pegs, which were 
painful to remove.* 

Montgomery f records a case of hereditary and continuous 
shedding of nails; one or two at a time became dull yellowish- 
white over the lunula, and then became detached from behind 
forwards. The process of shedding occupied about three 
months, while in from three to eight months it was completely 
restored, and then another one would be attacked. His mother 
and uncle shed their nails in the same way, and other members 
of the family had bad nails. 

In an anomalous case of recurrent erythematous inflamma- 
tion in a boy of four, all the hair and nails were shed, and re- 
growth was very feeble and temporary. The cutaneous inflam- 
mation did not affect the scalp, but the ends of the fingers. 
Shedding occurs in epidermolysis bullosa also, and it may result 
in permanent destruction of the matrix. 

R. Hilbert J reports a case where for four years in succession, 
and always in September, the great toe-nails were shed without 
antecedent symptoms or known cause, except that before the 
first attack the patient had had a difficult mountain tour. 
Dubreuilh § recorded seven cases; some he thought were 
tropho-neuroses, others were unclassifiable. 

The nails have also been shed after prolonged exposure to 
the Rontgen rays, but more frequently the effects are those of 
chronic onychitis. 

Of all these conditions a moderate degree of onychauxis or 
hypertrophy combined with a certain amount of atrophic 
change, the result of symptomatic inflammation of the matrix, 
is the most common. The nail becomes more or less thickened, 
its texture less dense, owing to the loosened adhesion of its 
cellular elements, the surface loses its luster, discoloration of 
a dull yellowish hue ensues, and the surface may be more or 

* Plate XXXVIII.. International Atlas. 

f Montgomery, Avier. Jotir. Ctit. Dz's., vol. xv. (1897), p. 374. 
^Quoted by Shoemaker, loc. cit. 

§ Dubreuilh and Freche, " Decollement des Ongles," Jour, de Med. de 
Bordeaux, Nos. 26 and 27, June and July, 1901. 



1254 DISEASES OF THE SKIN. 

less irregular from imperfect growth, and is furrowed and pitted 
in various ways. These conditions are most commonly the re- 
sult of eczema, psoriasis, syphilis, or the trichophyton fungus. 

Of atrophic conditions — furrowing, discoloration, loss of pol- 
ish, and the pitted or worm-eaten appearance already alluded 
to, and white spots, are the most common symptoms. The nail, 
however, may be thinned and softened, or split, brittle, and 
crumbling. A good example of the latter is seen in some cases 
of nodulated leprosy, where the original, perhaps thickened, 
nails may be replaced by a few dirty greenish, horny flakes on 
the stumpy ends of the fingers. The nails may also be reduced 
to a rudiment in sclerodactylia. Sometimes these changes are 
due to local trophic defects of the matrix of the nails them- 
selves, at others to some more distant nerve affection, c. g., in 
neuritis as in " Glossy Skin " (see that disease). In partial de- 
struction of the nerve supplying the digit, painful ulceration of 
the matrix may occur. 

In gouty persons, one or more of the nails may form a cen- 
tral ridge and split down the center with slight eversion of the 
edges of the split. 

Onychorrhexis. Brittleness of the nails is sometimes con- 
genital, sometimes acquired. In a form described by Du- 
breuilh and Freche * there is also thinning and longitudinal 
furrowing; the free border is serrated by longitudinal splitting 
extending towards the base. It may be associated with anoma- 
lies of development or other nervous affections. In pompholyx 
the nails in some cases split and chip (Hutchinson). 

Unna f describes a peculiar case in which longitudinal tu- 
mors appeared in a circumscribed part of the nail, especially 
in the median line, over which the nail substance was raised up, 
became gradually atrophied, split, and the tumor was thus 
exposed. It was of chronic origin and due to venous stasis and 
was sometimes associated with symptoms of deeper venous 
stasis of the whole finger-end. Treatment was of small avail, but 
the condition underwent spontaneous improvement and healing. 
He recognized three stages: first, great longitudinal ridges with 

* Third Intemat. Cong, of Derm. , London, 1896, p. 845. 
\Viertelj f. Derm, u. Syph., vol. ix. (1882), p. 3, with woodcut. 



DISEASES OF THE NAILS. 



1255 



decreased cohesion of the nail cells; secondly, reddish, longi- 
tudinal swellings; and thirdly, complete separation of the nails 
into two halves. 

Ridged Nails. Longitudinal ridging sometimes occurs, but 
not with any definite etiology. In one form the ridges multiply 
and the disease goes on for years, and finally, the nail is lost. 
In one of Hutchinson's cases the nail fold grew forward and 
half covered the nail. A curious condition, in which all the 
nails of the fingers, but not the toes, had a central longitudinal 
ridge, * with a parallel groove on each side, came under my 
notice in a boy of twelve. The nail had lost its polished sur- 
face, being rough and fibrous-looking; the substance was 
thinned and had gradually become soft. No cause could be dis- 
covered, except that the hands were very cold. Possibly this 
was a minor degree of the condition above described by Unna. 

Separation of the nails from the nail-bed without actual shed- 
ding is frequently seen in slight degrees in some inflammations 
of the finger-tips, and also in cases without traceable cause. 
An extreme case is reported by Casteret,f in which the whole 
anterior portion of the nail-blade was separated and raised up 
into an arched tunnel, exposing the whole nail-bed. The patient 
was a young adult, and no cause could be assigned for it. A 
slight degree of separation, either at the side or end, is common 
in psoriasis, and in a woman, set. forty-two, with psoriasis, the 
front half of all the nails was separated. 

In a case of Sangster's f separation was followed by suppura- 
tion, and this by shedding of the whole nail, in a child, aet. seven. 
In a case of thickening and striation, vertical and transverse, 
Hallopeau and Le Damany found three kinds of cocci, which 
by cultivation gave short and long bacilli. The nails improved 
with a one in twenty salicylic acid application. 

Very few investigations into schizomycetic invasion of the 
nail have been made, but in the dirt under the nail all sorts of 
microbes have been found by Mittmann, including the virulent 
bacillus pyocyaneus and fluorescens, and the staphylococcus 
aureus and albus. § 

*Fig. 8 of Atlas, Plate XC. 

\ Annales de Derm, et de Sypk., vol. vii. (1896), p. 1419. 
iSangster. Clin. Soc. Trans., vol. xiii. (1880), p. 149. 
%Ann. de Derm, et de Syph., vol. vi. (1895), p. 538. 



1256 DISEASES OF THE SKIN. 

White nails may occur in spots, bands, and in very rare in- 
stances all over. White spots are common, especially in young 
people; their mechanical cause is the presence of air between 
the lamellae of the affected part, but their origin is unknown. 
In some cases they can be shown to be part of trophic changes. 
W. Sykes * states that in his own person he could produce 
white specks by scraping, pressing back, and cutting the skin 
over the lunula, but they are not always of traumatic origin. 
Bielschowsky f records a case of a man with peripheral neuritis, 
in whom white spots appeared at the lower part of the finger- 
nails, rapidly grew, and in three weeks coalesced into a band 
across each nail a millimeter wide. The toes were not affected. 
These bands or spots sometimes are a milder expression of 
trophic defect than the furrows above described. Dr. Long- 
streth I suffered from relapsing fever, and a separate band bore 
witness to each relapse. Other cases of serious illness inducing 
white bands, instead of transverse depressions, are known. 
Langdon Down's case is especially noteworthy, but according 
to Heidingsfeld, cutting and pressing back the nail fold is the 
most common cause of the band form, and he had seen seven 
cases from this cause. 

A case is recorded by Morison § of Baltimore, in which trans- 
verse bars of white, alternating with the normal color, appeared 
without ascertainable cause on the finger-nails of a young lady, 
and remained unchanged for months. Giovannini and Unna || 
both record instances of complete whitening of the nails of the 
hands only, both in men. Giovannini's case began at the age 
of twelve, after typhoid fever; the hair was unaffected. Unna's 
case was probably congenital, and there was a partial condition 
of ringed hair also present. He calls the three forms leuko- 
nychia punctata, striata, and totalis. 

Joseph's If second case was that of a young girl. There was 

* Brit. Med. Jour., vol. ii (1897), p. 1260. 

f Quoted in Supplement, Brit. Med. Jour., January 17, 1891. 

\ Quoted by Shoemaker, loc. cit. 

§ " Leucopathia Unguium," Viertelj.f. Derm. u. Syph., vol. xv. (1888), 
p. 3, with plate. 

I Giovannini, " Canities Unguium "; Unna. " Leuconychia and Leuco- 
trichia" — both in International Atlas, Plate XIX. 

1" Annates, vol. x. (1899), p. 164, and Derm. Zeits., vol. v. (1898), p. 651.. 
He had previously published a case in Neisser's stereoscopic Atlas. 



DISEASES OF THE NAILS. 



I2 57 



sub-ungual keratosis at the borders, and their convexity was 
directed below and their concavity above. There were also 
changes in the teeth. Parkes Weber and Krieg's * case was 
a man, set. fifty-two, with old valvular disease of the heart; 
the toe-nails were partially affected, the finger-nails were flat- 
and one was " spoon "-shaped. In Forcheimer's \ case " spoon 
nails " were also present; all the nails were not involved in the 
leukonychia. 

Spoon nails, J; in which the nail is thinned and concave from 
side to side with the edges everted, and with hollowing to a less 
degree, sometimes antero-posteriorly, have been observed in 
some wasting diseases, but also there are a few cases on record 
where the etiology is obscure. It begins on one finger, and 
gradually involves the others. I have not heard of it affecting 
the toes. In a woman of fifty under my care, it came on along 
with lichen planus of the limbs about four years previously. 
Brindley James relates a case of a girl of twenty in which there 
was no apparent cause. Coleman and Taylor record a case 
in a boy of eight also without apparent cause, but the brother 
had Raynaud's disease. 

Eddowes showed a woman at Hutchinson's museum who 
had this condition, and said that all her brothers and 
sisters and all her father's brothers and sisters were affected 
in a similar way. The toes were slightly affected. In a case of 
Stephen Mackenzie's only those nails were affected in which 
there was end-joint rheumatism. Its association with leu- 
konychia has already been noticed. Julius Heller has also had 
a case, and he refers to a case recorded by Ball in 1874, in 
which the frequent immersion of the hands in strong potash 
appeared to be the cause. In Morrant Baker's case no cause 
could be assigned. Cohan's case was one of keratosis papil- 
lomatosus nigricans. It is, therefore, a trophic change which 
occurs with various associated conditions of which we do not 
know the common factor. 

Tylosis of the matrix I have once observed in a cowman, aet. 
twenty-three. The nail was raised from its bed by a homogene- 

* Brit. Jour. Derm., vol. xi. (1899), p. 120. 

f Quoted Monatsh. f. Derm., vol. xxviii. (1899), January No. 

% Heller suggests " Koilonychia " for this condition. 



1258 DISEASES OF THE SKIN. 

cms plate of horny epidermis, which filled up the usual interval 
between the nail and finger-end. It imparted a dirty yellow 
color to the anterior two-thirds of the nail. It appeared to 
begin at the free end, and had grown inwards like a wedge. 
The toe-nails were not affected. The man had hyperidrosis of 
the palms and seborrhea capitis. Le Fort met with two cases 
affecting the toe-nails. 

Etiology. — The causes of abnormalities of the nail are: 

1. Congenital, (a) Supernumerary nails, growing either on 
a supernumerary digit, or two on one digit, or growing in 
some abnormal position, as on the middle of the scapula (Tul- 
pius). It may be added that supernumerary nails may be ac- 
quired, as on the stumps of amputated fingers, or as I have seen 
in leprosy, where the terminal phalanx had been lost, (b) Con- 
genital onychauxis, when the digit on which it grows is ab- 
normally large, e. g., a patient of mine had congenital absence 
of the two middle fingers of the hand; the thumb and first finger 
were of enormous size, and the nails corresponded. In a case 
recorded by Keyes,* in a man, aet. forty-eight, the nail bed and 
consequently the nail itself extended beyond its usual limits 
laterally round the fingers and toes and forward over the ex- 
tremity of each digit. The nails themselves were normal in 
appearance and consistence. He called it megalonychosis. 
Ramsay Smith'sf case of a new-born infant showed a slight 
transitory condition of a similar character. 

A more common cause is ichthyosis (see that disease). An 
interesting case of onychauxis, with onychogryphosis, is re- 
corded by Sympson f of Lincoln, in which all the nails of the 
fingers and toes projected upwards from the matrix like horny 
pegs. Nicolle and Halipre § met with a somewhat similar con- 
dition in thirty-six members of a family in six generations, but 
the nails were furrowed and friable and showed lamellar separa- 
tion. 

There were also atrophic conditions of the hair. In one 
of the cases there was chronic periungual ulceration with 
frightfully offensive discharge, (c) Congenital absence or 

* N. Y. Medical Record, April 23, 1898. 

\J01tr. Anat. and Phys., vol. xxvi., 1892. 

% Lancet, April 14, 1888. 

% Annates de Derm, et de Syph., vol. vi. ( 1895), p. 804, illustrated. 



DISEASES OF THE NAILS. 1259 

atrophy is rare, but a few cases are on record.* A case with 
congenital thinning of the nails is depicted in my Atlas in the 
nail plate. Jacob f had a case with rudimentary nails in a boy 
of fourteen. 

2. Acquired onychauxis may occur from (a) unrestrained 
growth, of which onychogryphosis is an example, and is seen 
chiefly in bedridden and elderly people, or others who cannot 
or will not give their nails the requisite attention; (b) from 
elephantiasis Arabum and other causes of obstructed circula- 
tion, c. g., lateral pressure of tight boots, (c) Inflammation of 
the matrix, acute or chronic, whether idiopathic from injury, 
mechanical or toxic, parasitic or symptomatic. 

In a woman, set. forty-eight, after severe seborrheic eczema 
capitis et palmae, all the nails increased in thickness until they 
were at least half an inch thick and an inch and a half long, 
yellow and opaque, and very dense. After prolonged treatment 
the inflammation subsided, and as the hypertrophied nail grew 
out it was replaced by a nearly normal nail. Unna has also 
noted nail changes with seborrheic eczema, but Audry thinks 
the conjunction is extraordinarily rare. 

Acute idiopathic inflammations have already been treated of 
under Onychia. The nails are often accidentally involved in 
acute inflammations, such as erythema iris, pemphigus, yaws 
(Xichols), smallpox, the inflammation taking place beneath the 
nail and loosening its attachments more or less; spots of xan- 
thoma also sometimes occur in this position; and warts may 
grow beneath the nail in a flattened form. 

The chronic inflammations are generally the result of ec- 
zema, psoriasis, pityriasis rubra, lichen ruber, and in all these 
there is more or less discoloration and thickening, as a rule, 
often combined with pitting; but when they take an acute form, 
some thinning may be produced, as often happens in pityriasis 
rubra. The most marked instance of thinning and softening 
is that which occurs in pemphigus foliaceus, a disease which is 
chronic in duration, but acute in its manifestations. Other 
causes of atrophy are neurotic conditions, c. g., neuritis, al- 
ready alluded to, syphilis, and leprosy. Besides the vegetable 

* Petersen and Tarnowsky record cases reported loc. cit., p. 69. See 
also Med. Moderne, September 22, 1S96, by M. Jacob. 
\Malad. Cutan., vol. ix. (1897), p. 55. 



i 2 6o DISEASES OF THE SKIN. 

parasites of favus and ringworm, animal parasites may also 
affect the nail, as in the worst or Norwegian form of itch, never 
seen in this country; the chigoe or pulex penetrans of the West 
Indies; and in the case of some other tropical insects. 

The descriptions of these symptomatic affections of the nails 
are given under the various diseases which give rise to them. 
They are rarely congenital, but may be apparently idiopathic 
and localized in one or affect several nails, or it may be a part 
of the general malnutrition, and sometimes an early sign of 
nervous exhaustion. It is seldom possible from merely inspect- 
ing the nails to infer the cause. The diagnosis has to be made 
from the presence of eruptions elsewhere, or from other col- 
lateral circumstances. 

The nails also undergo more or less change in connection 
with more general affections. Thus in k< clubbed fingers " from 
obstruction to the circulation, as in many chronic cardiac and 
lung affections, the nails become rounded as well as of a bluish 
tinge. In hemiplegia growth is arrested, as a rule, but there 
may be thickening and broadening (Esbach). 

Eichorst records a case of pernicious anemia in which the 
nails were thickened, fissured, and crumbled at their free ends. 

In akromegaly there is marked striation, but not always 
increased growth. In aneurysms there is sometimes increased 
growth of the nails (Brocq), while in a fractured limb it is said 
that the nails cease to grow until bony union has occurred. 
Zeissler, however, suggests that the cessation of growth is due 
to interference with the circulation from the pressure of the 
bandages and splints. 

In keratosis nigricans, longitudinal striae and pitting some- 
times occur, and spoon nails and white bands have been noted. 

T. Acland relates a case of clubbing of the fingers, with 
separation of the anterior portion of all the nails from the 
matrix, which he thought was due to Raynaud's disease, but 
without any strong reason for the supposition. Of course in 
undoubted Raynaud's disease damage to the nails would nat- 
urally result. I have seen separation from the matrix even 
down to the lunula several times without any suspicion of Ray- 
naud's disease. 

Reedy nails, in which the natural longitudinal striae become 
very marked, apparently from wasting of the intermediate por- 



DISEASES OF THE NAILS. 1261 

tion, are regarded by many as a sign of gout;"* but they are 
also very common in old persons who show no other sign 
of gout, and are then only one of many other senile atrophic 
changes. 

Transverse furrows show that the nails also take their share 
in severe illness — e. g., in fevers, choleraic diarrhea, pneumonia, 
etc., there is deficient growth, and after recovery a furrow re- 
mains as a memento until it has grown to the end of the finger. 
The thumb is most affected and the index finger is next in 
degree. In relapses of typhoid and similar conditions more 
than one furrow may be present, being the record as well as 
the consequence of the illness. Wilks relates an interesting 
case in which two furrows recorded sea-sickness on August 28 
and October 8 respectively. 

White bands may take the place of furrows, and in a case 
of Hutchinson's a band of hemorrhage marked one attack of 
illness and a furrow the next. 

Diagnosis. — The diagnosis of the origin of the nail change can 
seldom be made from the naked-eye appearances of the nails 
themselves. If due to a constitutional condition, such as gout, 
syphilis, or leprosy, it is by the evidence of these diseases else- 
where that the cause of the disease of the nails is inferred. The 
same is true for nail disease as a part of other cutaneous inflam- 
mations, eczema, psoriasis, tinea tonsurans, etc. It is very rare 
for the nail affections to be the sole manifestations of such dis- 
eases, and when they are so the diagnosis is little more than 
guesswork, unless there is a history of previous cutaneous dis- 
ease. Hutchinson, however, considers that the separation of 
the nail from its bed, either at the side or end, is characteristic 
of psoriasis. Where the possibility of a fungous origin is pres- 
ent microscopical examination of nail scraping (after pro- 
longed soaking in liquor potassse B. P., or a forty per cent, 
solution may be used to get more rapid results) is essential, 
but it is not always easy to detect the spores and mycelium in 
nails only slight affected. 

Treatment. — Only the treatment of those nail affections which 
are not alluded to elsewhere is described here. 

*Laycock first observed the connection, and Duckworth insists strongly 
on it. 



1262 DISEASES OF THE SKIN. 

In severe onychia the tension may be relieved by incisions and 
removal of the nail, and the surface cleaned up by iodoform or 
iodol and wet boric lint under oiled silk. Thorough local dis- 
infection, in short, is essential. Internally, the treatment must 
be a supporting one — quinine in full doses, sulphid of calcium 
half a grain three times a day, a generous dietary, and a brac- 
ing climate. 

Onychogry phosis only requires that the superfluous part of 
the nail be removed, after softening by soaking in hot water. 
Hans Hebra treated a case successfully by insinuating a flat 
platinum knife of a Paquelin's cautery under the nail until he 
had burned away all the abnormal accumulation, for which 
eighteen sittings were required; the nail grew up healthily and 
remained well. 

In in- growing toe-nail the nail should be softened, scraped thin 
in the center, the unhealthy granulations destroyed with acid 
nitrate of mercury, the sharp edge of the nail removed, and the 
raw surface treated with wet lint under oiled silk, applied with 
pressure, a part being pushed between the nail and the skin. 
In some cases avulsion of the nail is required, and in all cases, 
properly made boots should be used, or the evil will recur. 
Scott-Battam's treatment is a good one. " First wash and dry 
the parts, and then thoroughly rub the granulations with solid 
nitrate of silver. Since the introduction of cocain this proceed- 
ing can be rendered practically painless. Next, cut small pieces 
of fine Turkey sponge, and press them well down between the 
nail and the granulations, inserting a small piece beneath the 
inner free edge of the nail. Pressing this sponge pad downward 
and inward, fix it in place by winding a long, narrow strip of 
plaster round and round the toe, commencing from the outer 
side, the aim being to compress the granulations, and draw 
them as far as possible from the nail. A soft, easy shoe should 
now be worn, and patients can pursue their ordinary avocations 
without risk. Some aching pain often follows, but this is soon 
succeeded by a considerable feeling of relief. 

" The dressing should be removed and the process repeated 
in two days' time. A sulcus will then have formed between the 
flesh and the nail, and on removing the crust formed by the 
nitrate of silver, a healthy ulcer will be found to have replaced 
the exuberant granulations. 



DISEASES OF THE NAILS. 1263 

" On the fourth or fifth day, after well soaking the toe, apply 
cocain, and endeavor to insert a small piece of sponge beneath 
the edge of the nail, which is now more fully exposed, or a 
piece can be removed with fine scissors. A mixture of iodoform 
and alum is now dusted in, and the sponge compress applied as 
before. In a week or ten days' time the process is repeated, 
especially if the ulcer is not healed. After a similar interval the 
raw, tender surface will be found to be hard and painless. It 
is well to continue treatment a little longer, and the dressing 
can be worn for two or three weeks without discomfort." 

In cases of chronic onychauxis, where the cause is not ascer- 
tainable, the same treatment as for chronic psoriasis of the 
matrix is generally successful, together with the administration 
of arsenic, or the remedies suitable for any departure from 
health which can be detected. One of the most generally useful 
for chronic onychitis is a salicylic ointment oss or 5j to 5j of 
lanolin c. oleo, spread on strips of linen, and bound closely on 
night and day, pushing the ointment well underneath the pos- 
terior nail fold. When the skin begins to peel the ointment may 
be intermitted for a few days. Shoemaker strongly recommends 
oleate of tin gr. 20 to oj to §j of lard for cases of this kind. The 
nail is wrapped up in it as just described. A little carmin may 
be added to color it. T. H. Irquhart also speaks well of it from 
experience on his own person. 

Sabouraud recommends constant soaking in a solution of 
iodin 1 in 1000 dissolved by the aid of iodid of potassium. A 
one in twenty solution of salicylic acid in spirit is also useful. 
All these remedies act by their microbicide action, for, as has 
been pointed out, in a large number of nail affections, primary 
or secondary microbic invasion occurs. Whichever application 
is selected, daily scraping the affected nail with a piece of glass 
increases the penetration and therefore the efficiency of the 
applications. 



CLASS X. 
HYPHOMYCETIC PARASITES. 

The diseases included in this class are due to the various 
members of the hyphomycetes or fungus family. They are: 

I. Favus: due to achorion Schonleinii. 

II. Common ringworm: due to various species of tinea tri- 
chophytina. 

III. Tokelau ringworm: due to tinea imbricata. 

IV. Tinea versicolor: due to microsporon furfur. 

V. Erythrasma: due to microsporon minutissimum. Some 
think this is a micrococcus, and that it belongs therefore to the 
schizomycetes. 

VI. Pinta: disease of Mexico; fungus unnamed. 

VII. Mycetoma: due to chionyphe Carterii (?), one of the 
actinomyces; or to the streptothrix or discomyces madurse of 
Vincent. 

VIII. Actinomycosis: due to actinomyces. 

IX. Blastomycosis: due to blastomyces, or yeast plant. 
Only the first two diseases affect the hair follicles as well as 

the rest of the skin. 

Mycetoma, actinomycosis, and blastomycosis are not limited 
to the skin, but affect other tissues, and there is reason to be- 
lieve that mycetoma is really a form of actinomycosis. 

IV., V., and VI. affect only the surface layers, and produce 
discoloration only. 

In order to find the fungus, if merely for diagnosis, it is suffi- 
cient to wash the hairs in ether to remove the grease, and then 
soak them for a few minutes in liquor potassse B. P., that is, 
a six per cent, solution of caustic potash. When details of the 
arrangement and character of the fungus are desired prolonged 
soaking in the potash solution is often necessary, or staining 
methods may be employed (see Appendix), especially if per- 
manent specimens are required; but for ordinary clinical diag- 
nosis the potash solution is sufficient. The following favus and 

1264 



FAVUS. 1265 

ringworm original illustrations are all made from fresh speci- 
mens after soaking in the above potash solution. The fungus 
will resist the action of the potash for several days, although 
the scales or hairs which it permeated are dissolved. 

When a more complete examination still is required, culture 
experiments on suitable media, such as the potato, beer maltose, 
gelatin and agar agar, etc., are necessary. Unna insists on the 
value of pepton lsevulose as a uniform cultivating medium. This 
takes the matter beyond clinical medicine and the scope of this 
work, and for this Sabouraud's, and Fox and Blaxall's re- 
searches should be studied. Leslie Roberts' investigations in 
another direction are also deserving of attention. 



FAVUS.* 

(Lat. for honeycomb.) 

Synonyms. — Honeycomb ringworm; Tinea favosa; Tinea vera; 
Tinea lupinosa; Porrigo lupinosa; Porrigo favosa; Fr., 
Teigne faveuse; Ger., Erbgrind. 

Definition. — A vegetable parasitic and contagious affection of 
the . scalp and general body surface, characterized by sulphur 
yellow, cup-shaped crusts embedded in the epidermis, and in 
hairy parts pierced by a hair. 

This disease is extremely rare in England (1 in 2000 in my 
practice), but is common in Scotland (31 in 2000, McCall An- 
derson), while in France f and Poland it is almost as common 
as tinea tonsurans is in this country. Its favorite seat is the 
scalp, but absolutely no part of the body surface is exempt from 
its attack, and it may even affect mucous membranes, such as 
the glans penis, and in one instance, the mucous membrane of 
the stomach. It differs in aspect somewhat according to 
whether it attacks hairy or non-hairy parts of the body. 

Symptoms. — It appears first on the scalp as a very small, 
sulphur-yellow disc, called a scutulum, embedded in the epi- 

* Author's Atlas, Plate XCI., Figs. 1 and 2, as it affects the scalp and 
glabrous skin. 

f Feulard stated in 1892 that in France about one thousand conscripts, 
chiefly from the country districts, were annually rejected on account of 
f avus, but that the number was gradually diminishing. 
80 



1266 DISEASES OF THE SKIN. 

dermis, and pierced by a hair. If, when it has attained to the 
size of a hemp seed, it is dug out and removed with its attached 
hair, the under surface is found to be smooth, convex, moist, 
and slightly greasy to the touch, while the upper surface is 
slightly concave, and -mixed with the whitish epidermic scales, 
which also remain attached to the border like a collar. There 
is a depression left in the rete from which it has been dug out, 
but this is only due to compression of the cells, which soon 
sw T ell and fill it out when the pressure has been removed, unless 
the crust has attained to some size and has been long there, 
when there may be serous exudation or even bleeding at the 
time of removal of the crust. 

As the small disc enlarges it projects at the periphery more 
than at the center, and thus a cup-shaped depression is pro- 
duced; still growing larger, it may reach to the size of a six- 
pence. These large crusts are relatively flatter and furrowed 
by concentric rings or variously fissured, or they may grow 
vertically more than peripherally, and thus form elevated, irregu- 
lar, craggy masses, with a white center, but the typical sulphur 
yellow shows at the periphery, unless blood-stained from 
scratching. After having attained its full development, varying 
much in extent and duration, but generally taking several 
months, it becomes paler and of a dirty yellowish white. The 
margin is elevated through the epidermic covering, and the 
whole shells off, either spontaneously or from some trifling 
friction, and the skin beneath, from the long-continued pres- 
sure, is left depressed, hairless, thin, white, and glistening; in 
short, an atrophic scar results. 

The hair appears dry, lusterless, and brittle, and sometimes 
splits longitudinally, getting separated more or less from its 
root attachments, so that it falls out, or is easily drawn out with 
portions of the root sheath attached; and the papillae being 
often atrophied from pressure, no new hairs are regenerated, 
and the follicle becomes obliterated. Itching and a sense of 
fullness are the only symptoms complained of, but there is a 
peculiar, musty, strawlike or mousy odor when the disease is 
at all extensive. 

Sabouraud says that favus always leaves a fringe of hair on 
the forehead unaffected. This mav be true as a rule, but I 
have seen this fringe destroyed by the fungus in one case. 



FAVUS. 1267 

Variations. — Such is the course and development of a single 
scutulum (F. lupinosa), but in neglected cases many may 
coalesce into an irregular mass, with a curvilinear border, indi- 
cating the component cups of which it is made up, and accord- 
ing to the shapes and aggregation names were given in former 
days, but have now deservedly dropped into disuse. In such 
a case all stages may be presented at the same time. On one 
part of the scalp will be these masses; at another, isolated typi- 
cal favus cups; or again, white, atrophic scars, with the skin 
thin, shining, and stretched over the bones, and at intervals, thin 
tufts of hair, whose follicles have escaped the general destruc- 
tion. In the favus masses themselves the hair is dull, dry, and 
dusty-looking, and easily removable, unless there remain a few 
unaffected, and therefore healthy hairs. Complications may 
arise, of which the most common is pediculosis, with its usual 
concomitants, eczema, impetigo contagiosa, and enlargement 
or even suppuration of cervical glands, etc. 

Simon describes superficial erosion of the scalp from pres- 
sure of the favus masses, and others have described necrosis 
of the skull and favus ulcer; but since neither Hebra nor Ka- 
posi has met with them, such conditions must be extremely 
rare, and it is probable that the ulcers are really only the 
pressure-pitting already described. 

Favus is an essentially chronic disease, beginning in child- 
hood and lasting for many years; one of my cases, a German 
boy, set. fifteen, had had it since he was two years old, and 
Kaposi speaks of it lasting until the patient was forty years old 
or more — in fact, as long as there were any hair follicles re- 
maining to be attacked; in other cases it spontaneously stops, 
leaving one or more bald patches. 

In a case at the Hopital St. Louis * it had existed untreated 
in a man of forty-two from the age of thirteen years all over 
the scalp. Only in the last six months had the lower limbs been 
attacked, and in a month from the onset spread nearly all over 
them. He had not transmitted the disease to his wife, though 
he had been married five years. 

On the non-hairy parts, while the scutula present exactly 
the same characters, variety, and development, there is often an 

* Brit. Jour. Derm., vol. ii. (1890), p. 149. Letter by L. Wickham. 



i 2 68 DISEASES OF THE SKIN. 

additional feature, somewhat resembling tinea circinata, viz., a 
round, red, scaly patch, which develops into a circle with a 
paler, scaly center and a red, elevated margin, smooth, papular, 
or vesicular. On the surface of the skin sometimes several 
concentric circles form round a central favus cup, which has 
developed on the initial disc, or again, several circles coalesce 
and form a gyrate pattern round the crust or crusts, which may 
also be present on the margin; when there are no crusts the 
circles may disappear spontaneously, after growing to a vary- 
ing degree. Favus of the free surface has generally, but not 
always, originated from the scalp. As a rule, when once it has 
commenced, it develops more rapidly than on the scalp, and the 
lanugo follicles being more superficial, there is a far greater 
chance of its spontaneous disappearance, but sometimes it per- 
sists for years (twenty years, Michel), and in long-standing 
cases, produces atrophic scarring, as on the scalp, though there 
is here also a better chance of the scar being eventually 
obliterated. When first inoculated circles of herpetiform vesi- 
cles often form, the characteristic cups not appearing till a later 
period. 

When neglected it may extend over nearly the whole of the 
body and limbs, as in Roddick's case,* and sometimes time and 
the patient's idiosyncrasy modify the appearances. In a case 
shown by Hutchinson at the Dermatological Society, a boy of 
fourteen, " the whole of the scalp hair had been destroyed, and 
the scalp reduced to the condition of a scar. The face, part of 
the scalp, and the fingers were covered with thick hornlike 
crusts. The nails were thickened and broken up. On many 
parts of the body and limbs there were crusts and conspicuous 
scars. The peculiarity was that nowhere was there any crust in 
the least resembling favus, nor was there any approach to the 
peculiar ocfor of that malady, but the fungus of favus had been 
found both in the crusts and in the scrapings of the nails, but 
only after very careful search; moreover, two cases of favus 
arose in the ward while he was in the Plymouth Hospital. The 
boy's lips were excoriated and the mouth generally inflamed. 
His circulation was feeble and his hands and feet dusky." 

In a unique case of universal favus, shown by Kaposi and 

* Montreal General Hospital Reports, vol. i., Plate VIII. 



FAVUS. I2 6 9 

Kundrat * to the Society of Physicians of Vienna in October, 
1884, and the morbid specimens subsequently on November 
28, the patient died from gastro-intestinal irritation with uncon- 
trollable diarrhea, and at the post-mortem erosions and diph- 
theritic swellings were found in the mucous membrane of the 
stomach, and the intestines contained foul, putrescent masses 
and much mucus. These swellings in the stomach were proved 
to be due to the favus fungus; and there was a little fungus 
found in the intestine, but the great bulk had undergone putre- 
faction. 

Dubreuilh recognizes three clinical varieties: 

1. A pityriasic, or scaly variety, easily confounded with 
psoriasis of the scalp. 

2. An impetiginous, or pustular variety, in which the favus 
lesions are covered with crusts like impetigo contagiosa, or 
some pustular eczemas, a variety previously described by Au- 
bert. 

3. An alopecial variety very difficult to distinguish. In this 
variety there are serpiginous plaques, smooth in the center and 
surrounded by a slight zone of folliculitis. The hairs in this 
zone pull out easily with a thick, soft, transparent sheath, and 
they spring from a red, very slightly raised acuminate projec- 
tion with a small scale or grayish-yellow crust upon it. It is, 
therefore, an entirely follicular favus, resembling lupus ery- 
thematosus of the scalp, and still more folliculitis decalvans; in- 
deed, Dubreuilh is inclined to regard the latter affection as 
really follicular favus. The chief diagnostic points are: The 
long duration of the affection — often months or years; the 
alopecia being cicatrical and smooth; and finally, the minute 
yellow crust at the base of the hair, which is absent in folliculitis 
decalvans. The hairs are also dry and dull, and they pull out 
very easily. In dark-haired people the difference in the color 
of the hair is very noticeable. 

Favus of the nail is extremely rare, and is thus described by 
Kaposi: " One or more nails may be affected in one of two 
ways: in one a scutulum is formed in the deep cells of the nail 
substance, as well as the structure of the nails permits, show- 
ing through the smooth layer of the nail over it as a sharply 

* French resume of the case, Annates de Derm, et de Syfth., vol. for 
1895, p. 104. 



1 270 DISEASES OF THE SKIN. 

defined, pale sulphur-yellow mass; it occupies only a small 
part of the nail, either at the side, from the fold to the center, 
from before backwards, or near the lunula. In the other va- 
riety it is indistinguishable, except by the microscope, from 
any other form of onychitis ; the nail is dry, lusterless, discol- 
ored, and opaque, furrowed, fissured, split into laminae, and 
raised up from its bed. When scrapings are placed under the 
microscope, mycelium and spores of the same characters and 
arrangement as in the root sheath of hair are to be found. As 
it is almost invariably derived from inoculation from scratching 
the scalp, evidence of the existence of the disease either in the 
present or past can always be found, and will assist in the 
diagnosis." 

In extreme cases further changes occur; thus in Morris' 
case * no trace of true horny substance remained, being replaced 
by an irregular, lumpy, dirty yellowish crust. Fabry f found the 
changes limited to the epithelial portion, the breeding-place 
being between the corium, papillae, and the epithelial pegs, and 
thence the fungus advanced into the upper layers of the un- 
cornified epidermis, but not into the horny layers. 

Etiology. — Direct contagion from person to person is the 
usual mode of origin, but it may also be derived from animals, 
rabbits, ferrets, fowls, dogs, cats, and mice, which are all liable 
to it, and therefore possible sources of contagion, cats being 
the most common source of it. It has occurred under poultices 
without any ascertainable source of infection, the spores doubt- 
less having been derived from the air, and found a favorable 
nidus in the warmth and moisture of the poultice. It is, how- 
ever, far less easily communicated than ringworm, as it de- 
velops much more slowly, and therefore requires to be undis- 
turbed for some days after deposition, the most favorable posi- 
tion being at the orifice of the hair follicle; J these conditions 
are therefore seldom fulfilled, except among the unclean and 

* Brit. Jour. Derm., vol. iii. (1891), p. 101. A generalized case (photo). 
He refers to a case of Gull's with the nail affected. 

\ Fabry, Archivf. Derm. u. Syph., 1890, p. 21, illustrated. 

\ Peyritsch found that if the skin immediately round a hair was pricked, 
and water impregnated with favus spores deposited immediately on it 
and allowed to evaporate, inoculation seldom failed, but it took three to 
six weeks to develop (quoted in Hebra. vol. v. p. 163). 



FAVUS. 



1271 



neglected, and it is therefore where dirt and squalor reign that 
it finds most congenial quarters. 

Kaposi says it is very rare for it to spread in a family, school, 
or community, but this is surely an error. The following cases 




Fig. 89. — Hair shaft and hair bulb from favus. X 700 (Kaposi). 
a, hair bulb; b, b, root sheaths, both being abundantly infiltrated with 

fungus. 

came under me at the East London Hospital for Children: 
The disease was probably derived from a cat, in which the hair 
came off in patches. The family lived in great poverty and dirt, 



1272 DISEASES OF THE SKIN. 

and their heads swarmed with pediculi. A girl, set. seven, was 
the first infected; when seen, six months after infection, the 
whole scalp was affected, and there were patches on the 
shoulders and arms. A brother, set. nine, was next attacked, 
four or five months before he came to the hospital. It began 
in the front of the ear, and spread all over the head in a month ; 
it appeared on the arms about the same time, but had only been 
present for a month on the thigh. The largest isolated patches 
were of the diameter of a good-sized pea, but compound 
patches were sometimes two inches in diameter; the glands in 
the neck were much enlarged, but where the hair was not cut 
it was full of nits. Another brother, set. eleven and a half, had 
only had the disease one month, and it was limited to the right 
parietal region. Cases which have arisen in hospital from con- 
tact with a favus patient have already been mentioned, and I 
have witnessed one occurrence of the kind. 

Pathology. — The disease is due to the infiltration of the epi- 
dermis and hair follicles with the mycelium and spores of a 
fungus which is usually called achorion Schonleinii, though 
some observers claim that this comprises several distinct 
species. The spores generally gain access into the skin by the 
orifice of the hair follicles, where they have sufficient space to 
develop round the shaft of the hair, and separate the layers of 
the epidermis between which it grows, and, except in the neigh- 
borhood of the hair where it is held down, elevate the upper 
portion of the epidermis to about one-sixteenth of an inch 
above the surface at the periphery, sloping down towards the 
center, and thus the well-known cup shape is produced. The 
rete cells below are soft, and get depressed by the downward 
pressure of the growth, and if not released by the removal of 
the favus mass, ultimately atrophy, together with the immedi- 
ately subjacent tissue, and thus produce atrophic scarring. 
More or less inflammation of the cutis is produced by the pres- 
ence of the fungus, and Robinson attributes the cicatrization 
to this cause; he also describes cystic degeneration of the sebace- 
ous and sweat glands, and consequent retention of secretion. 
Leloir and Vidal figure also the dissociation and infiltration of 
the connective tissue by the fungus* spores. 

Unna ascribes the cup shape, which is present even when the 
scutulum is not seated at a hair follicle, to unequal growth, the 



FAVUS. I273 

base and sides growing more vigorously than the center of the 
scutulum, which at first rests on the lower strata of the horny 
layer, and is surrounded by the middle and upper strata which 
compress it, though it may become free subsequently. A dis- 
tinguishing feature of the scutulum, he says, is the perpendicu- 
lar growth of the filaments from the horny layer. 

Anatomy. — When a section is made through a scutulum, there is first 
a layer of horny cells; beneath this lies the scutulum, still in the horny 
layer, and consisting solely of hyphse and spores, Unna * and Kellogg say 
with the mycelial threads growing perpendicularly, which Unna regards 
as a charteristic feature of favus. This differs slightly from Bennett's 
original description. He says that at the top of the scutulum there 
is a layer of finely granular, viscid material, consisting of a mixture of 
disintegrating epidermic cells and gland secretion, and this is continued 
for a considerable depth, and forms a kind of supporting stroma for the 
long mycelial threads, which give off branches more and more frequently, 
until they terminate in the production of conidia, which become so abun- 
dant that the center appears to consist of little else. Individual threads 
of mycelium may be smooth-bordered, small, and with or without septa 
or nuclei; but most of them are moniliform, the individual segments 
varying in length and diameter, but thicker as a whole than the smooth- 
bordered threads. The spores may be globular, discoid, oblong, or poly- 
hedral, with a central nucleus, and this, when large, gives the appearance 
of a double contour. Unna and Mibelli agree that the bulb is always 
free from fungus, and that the hair sheaths rarely, and the hairs them- 
selves never, show splitting. There is always atrophy of the sebaceous 
glands, and in the late stage the elastic tissue is completely atrophied. 
Cocci and other foreign bodies are only found in old broken-up crusts, 
never in the recent scutulum. To see the fungus in the hair, the latter 
must be soaked in the B. P. solution of caustic potash (six per cent.) and 
flattened out slightly; both mycelia and conidia can then be shown 
abundantly in the hair shaft, running for the most part, but not alto- 
gether, parallel to the axis of the shaft. It appears probable that the 
fungus gains entrance into the hair at the bulb where the cells are soft, 
though to a less extent it may invade the hair through the cortex also, 
but it does not seem to go much beyond the level of the root sheaths. 
The threads and conidia run in all directions, and in parts get between 
the root sheaths and the hair shaft, and separate the latter more or less 
from its attachments, so that it is, as a rule, easily withdrawn. One of 
the results of the injured nutrition of the shaft is, according to Aubert 
and Robinson, a longitudinal striation caused by air between the fibers, 
which simulates mycelium. Robinson considers this characteristic of 
favus, as it is not present in trichophyton tonsurans. In the ringed, 

*" Histopathology," p. 386, gives elaborate description of the anatomy 
of the scutulum. 



1274 



DISEASES OF THE SKIN. 



scaly form of eruption, which is seen on the free surface, the fungus 
elements spread laterally between the epidermis layers, while in the 
nails it develops very much in the same way as in the hair shaft. 

The Nature of the Fungus. — Although Schonleinii in 1839 first demon- 
strated the fungus which Remak christened after him, he did not recog- 
nize its etiological significance, which was first demonstrated indepen- 
dently, with a detailed description, by Griiby in 1841. 

The unity of the fungus in human favus remained undisputed until 
1886, when Quincke isolated three species, a, (3, y, afterwards reduced to 
a and y, the a fungus having been found in three cases only. Gerlach 




Fig. 90. — Fungus elements from the under surface of a favus scutulum. 

X 700 (Kaposi). 



had previously discovered a favus-like affection in fowls, due, as Megnin 
showed, to the epidermophyton gallinae, while Costantin and Sabrazes 
demonstrated a dog variety oosporo canina. Unna and Frank found 
three varieties, since increased to nine. In 1894. Bodin * again investi- 
gated the subject in the light of Sabouraud's observations on ringworm 
fungus, and came to the conclusion that, while there is a clinical unity 
in favus, i. e., that any variations in the clinical aspect of the disease do 
not correspond with microscopical and cultural differences, as is seen in 
ringworm, nevertheless he makes out five varieties: 1. The achorion 
Schonleinii of Krai. 2 and 3. Two species not previously described. 
4. Achorion entythrix of Unna. 5. The achorion atachton of Unna. 
On the other hand, Elsenberg, Krai, Dubreuilh, Pick, Mibelli, Plaut, 
Jadassohn, Marinelli, and Biro all agree that there is only one species. 
In 1893, Dubreuilh and Sabrazes again affirmed this. Klugef also in 

* Annates de Derm, et de Syph., vol. v. (1894), p. 1220. References to 
date. There is an error in his quotation from Quincke, where he says 
that it is /3 and y which are left, instead of a and 7. 

f Kluge, Derm. Zeitschr., vol. iii. (1896), p. 141. 



FAVUS. I275 

1896 found Quincke's y fungus only in six cases, both on the hairy and 
glabrous parts; and Danielssen,* after numerous inoculations on the 
human subject, concluded from the uniformity of his results that the 
achorion Schonleinii was the only fungus of favus. Obviously further 
research is required before the matter is beyond controversy, but the 
great variability of fungi under cultivation according to the media 
and to temperature, moisture, and access to air, must always be borne 
in mind, as Leslie Roberts' work demonstrates, and as Tischonthisie 
showed from one thousand cultures on fifty different media. An acid 
medium was the best. 

Diagnosis. — Favus is one of the most distinctive of skin dis- 
eases. The sulphur-yellow, cup-shaped scutula, with a central 
hair, if situated on the scalp, are quite unmistakable. 

In the later stage, when isolated scutula have coalesced into 
an irregular, mortar-like mass, some care is required to dis- 
tinguish it from psoriasis of the scalp. The edges keep their 
yellow color longest, the scales are less nacreous than those of 
psoriasis, and the loss of hair is much greater; and if there is 
any atrophic scarring that would at once exclude psoriasis, in 
which the hair also preserves its luster, while it is soon lost in 
favus. Of course, if the idea of favus was once suggested the 
microscope would solve the difficulty, and close examination 
would probably discover some yellow discs round the hair in 
some parts. 

When the scutula have fallen off or been rubbed off, unless 
there is scarring, it might be mistaken for seborrhea, a scaly 
eczema, a psoriasis, or tinea tonsurans. 

Eczema and seborrhea, however, are diffuse diseases with ill- 
defined borders, while in favus the border would be rounded 
and defined. Any loss of hair also that there may be would not 
be in patches, but rather a general thinning, and there would 
certainly be no scarring. It is in the absence of this only that 
difficulty can arise with any of these affections. 

In ringworm the resemblance may be very close, and even the 
microscope will not decide it always with certainty, and a culti- 
vation on potato or a suitable gelatin medium f might in rare 
cases have to be made. 

* Atlas of Vegetable Parasitic Diseases, Bergen, 1892. 

f A case by Fortunet and Courmont {Annates de Der?n , vol. i. (1890), 
p. 239) demonstrates well the difficulty sometimes experienced. Neither 
clinically, microscopically, nor culturally was a diagnosis possible until 



1276 DISEASES OF THE SKIN. 

In examining the scales for fungus it must be remembered 
that all the scales are not fungus-bearing, and it is necessary 
to examine scales and hairs from several places, and that care- 
fully, following the directions already given for the detection 
of fungous elements. If these be found it is not always possible 
to decide what form of mycosis is present from the conidia 
and mycelium, as they present great variation in aspect, even 
in the same species, but the distinctions laid down by Kaposi 
are true in the main, and are as follows: " In the achorion this 
consists in a predominance in the conidia forms, and in the 
great variety they exhibit as to size and conformation, in the 
comparatively short and remarkably jointed appearance of the 
mycelium, the scarcity of the smooth-bordered variety, and the 
ease with which it breaks up into single cells. In tricophyton 
the greater tenacity and stretched appearance of the much- 
branched and for the most part smooth-bordered mycelium, 
and the small number, uniformity, and comparatively small 
size of the conidia, are the chief features. In the microsporon 
furfur the peculiar arrangement of the conidia in heaps or 
clusters and their uniform and large size are the main char- 
acteristics." 

Careful attention to these criteria will assist in coming to a 
right conclusion, but they should always be taken in conjunction 
with the clinical features and not be relied on exclusively. As 
a last resort in cases of extreme difficulty the disease may be 
left untreated for a time, and in a week or two, if it is favus, 
some new yellow crusts will begin to form, while, if ringworm, 
the disease will show signs of spreading, with the production of 
new foci. 

Prognosis. — Although the disease is very obstinate and tedi- 
ous it may always be ultimately cured by steadily-persevered-in, 
judicious treatment. Thus a case of mine which had lasted 
thirteen years was cured by treatment in a year and a half. 
Favus is much more tractable on the skin than on the scalp, 
and is curable in a comparatively short time. Beyond the per- 
manent baldness and scarring favus was regarded as incapable 
of doing serious injury to the health until Kaposi's fatal case 
of universal favus already alluded to. 

a culture was inoculated on the head of a mouse, when typical favus 
was produced. 



FAVUS. I277 

Treatment. — The treatment of favus of the scalp is of three- 
fold character. The crusts must be removed, the epilation of 
the affected hairs efficiently practiced, and parasiticides applied 
so as to penetrate as deeply into the tissues as possible. For 
the removal of the crusts carbolized olive oil should be copi- 
ously rubbed in, and also left to soak in, by applying strips of 
flannel soaked in oil fastened on with a cap ; in twelve or twenty- 
four hours the crusts can be removed with a paper knife, and 
then the whole scalp should be thoroughly cleansed with soft 
soap. Epilation can then be proceeded with. Kaposi recom- 
mends that this should be effected by seizing some of the hair 
between the thumb and a flat surface like a tongue spatula; 
the force thus used is only sufficient to draw out the diseased 
hairs, leaving the healthy intact, and he claims that the process 
is almost painless. Parasiticides must then be rubbed or 
brushed in vigorously. These three measures should be daily 
repeated until a cure is effected, but as the diseased hairs be- 
come fewer epilation must be practiced with forceps, pulling 
them out singly, and in the direction in which they are growing. 
Where they are more numerous the large broad-pointed forceps, 
suggested by Dyce Duckworth, are of service, but the operation 
is too painful for very young children. 

The parasiticides, which should be applied immediately after 
epilation, are of the same kind as those recommended for tinea 
tonsurans, to which the reader is referred. I cured one case 
of twelve years' duration with resorcin 3j to §j of lanolin and 
oil. Mibelli recommends twenty per cent, of oleate of copper 
and washing with soft soap and spirit every two or three days. 

I have found a combination of ten per cent, oleate of copper, 
three to five per cent, chrysarobin, and lanolin and lard for the 
base, a very good application. Like all chrysarobin applica- 
tions it must not be used close to the face. 

After continuing these plans daily as long as there is any 
visible disease, which will take at least three months, and often 
more, a rest of a week or more may be given, to see if any 
fresh yellow spots develop ; and when these appear they must be 
attacked vigorously, as before, each hair being removed with 
forceps. The disease may be considered cured, when even after 
six weeks' discontinuance of treatment there is no localized 
scaliness, much less a scutulum, and no loose, dull, degenerated 



1278 DISEASES OF THE SKIN. 

hairs to be found. The treatment and necessary observation 
require, therefore, at least six months. 

On the free surface all that is required is to soften the crusts 
with oil, remove them and all epidermic scales by thorough 
washing with soft soap, and then rubbing in one of the parasiti- 
cides recommended in tinea circinata, or painting on linimentum 
iodi; two or three weeks of such treatment are, nearly always, 
sufficient for a cure. 

Favus of the nails is most quickly cured by avulsion of the 
nail, and applying the parasiticide directly to the parts beneath, 
but this severe procedure is rarely absolutely necessary, the 
treatment for tinea of the nail being equally efficient, though 
more tedious than avulsion. 

Favus-like lesions of the oral mucous membrane due to the 
aspergillus nigrescens have been described by Winfield * of 
Brooklyn. It was supposed to have been derived from eating 
moldy cheese. The disease was present on the hard and soft 
palate, the patches were edematous, lumpy, and covered with 
a dirty yellow deposit firmly attached to the swollen tissue be- 
neath, and there was slight bleeding on removal. The color 
of the recent deposit was that of favus scutula, but the older 
was of a grayish-brown. The disease was removed by the ap- 
plication of a twenty-five per cent, ethereal solution of peroxid 
of hydrogen. The unusual yellow color may be explained by 
some observations of Delepine. f On removal of strapping 
which had been round a fractured thumb for a month new 
patches of sooty material were noticed, each with an ulcer in the 
center. This was found to be due to the aspergillus niger. 
Cultivation experiments showed that the fungus developed best 
under warmth and moisture, and under these conditions on 
potato and glycerin agar a bright yellow pigment was de- 
veloped. 

* Amer. Jour. Cut. and Gen.-Ur. Dis., January, 1897. 
\ Trans. Path. Soc, 1891, p. 424, and plates. Abs. in Brit. Jour. 
Derm., vol. v. (1893), p. 121. 



TINEA TONSURANS. I279 

TINEA TRICHOPHYTINA.* 

Synonym, — Ringworm. 
Deriv. — Tinea, a moth, a worm. 

The fungi of ringworm, by their presence in the tissues, ex- 
cite lesions of different aspect, according to the region of the 
body attacked. The difference in appearance is so great that 
these regional variations were formerly thought to be separate 
diseases, and had distinctive names; and although they are now 
universally acknowledged to be only varieties of ringworm, it is 
still convenient to retain these names and to describe their 
clinical aspects separately. 

The varieties are tinea tonsurans, or ringworm of the head; 
tinea circinata, or ringworm of the body; tinea barbae, or 
sycosis, ringworm of the beard; tinea cruris seu axillaris, ring- 
worm of the pubic region and axillae, often called eczema 
marginatum; and tinea unguium or onychomycosis, ringworm 
of the nails. The lesions also differ according to the kind of 
ringworm fungus producing them. 

TINEA TONSURANS, f 

Synonyms. — Ringworm of the scalp; Herpes tonsurans; Tinea 
tondens; Porrigo furfurans; Trichonosis furfuracea; Fr., 
Herpes tonsurant; Teigne tondante; Teigne tonsurante; 
Ger., Scheerende Flechte. 

Tinea tonsurans is one of the most common skin diseases in 
this country. In my clinic it forms 10 per cent, of all cases, or 

*The generic name " herpes," used very generally on the Continent 
for ringworm, is justified by its derivation, epTreiv, to creep, but the term 
" herpes " is now so identified with the signification of groups of vesicles, 
and the parasitic origin of the ringworm group is so universally acknowl- 
edged, that tinea is more distinctive and expressive of the nature of the 
disease. 

\ Literature. — For the history of the disease and the prophylaxis and 
treatment as carried out in France, consult Feulard's " Teignes et teig- 
neux" (Paris, 1886); for resume of English methods of treatment, Alder- 
smith on Ringworm, 1898; and for pathology, Sabouraud's writings, 



i2 8o DISEASES OF THE SKIN. 

taking all varieties of it together, 13 per cent. On the other 
hand McCall Anderson's public statistics give only 7 per 1000 
for the scalp, while all the ringworms together constitute only 
14 per 1000; Bulkley's cases altogether were rather over 4.3 
per cent., while the statistics of the American Dermatological 
Association for 1897 yielded only 3.2J per cent. Practically it 
may be said to be confined to children; and although its direct 
effects upon the skin are usually insignificant, yet, owing to its 
being contagious and obstinate and the social ostracism it en- 
tails — interfering with education, etc. — its occurrence in a fam- 
ily or school is a real calamity, and it demands the greatest 
attention from the practitioner. 

The modern investigations into the fungi which produce ring- 
worm, initiated by Sabouraud, having in their main lines been 
confirmed by subsequent workers, it is necessary to treat the 
clinical aspects of ringworm from the pathological standpoint, 
and the pathology must, therefore, take the first place in the 
consideration of the subject. 

Pathology. — It has long been undisputed that the varied ap- 
pearances described under the comprehensive title ringworm 
are due to the presence of fungus elements in the epidermis, the 
hair follicles or hairs, or in the nails; but in spite of Griiby's 
observations in 1843, U P to the present decade, it was universally 
thought that only one fungus was the fans ct origo mali. 
Then Sabouraud, with the advantage of modern methods and 
inexhaustible patience, not only confirmed Griiby's results, but 
gave them a wide extension, and inspired a host of workers to 
investigate the subject on the same lines, the outcome of which 
will now be set forth. The fungi of ringworm may be divided 
into two main groups, the small-spored and the large-spored, 
or, the trichophyton microsporon * and the trichophyton 

especially " Les Trichophyties Humaines," with atlas of illustrations 
(Paris, Rueff, 1894/; Malcolm Morris' " Ringworm," 1898 — a good critical 
review of modern research, with abstracts of references to recent work. 
Fox and Blaxall, Brit. Jour. Derm., vol. viii., 1896, is a valuable record 
of laborious work. E Bodin, " Les Champignons parasites de rhomme," 
1902 — a good general resume of the subject to date. 

♦Sabouraud restricts the generic term " trichophyton " to the large- 
spored group, as the microsporon had " pectinated spore-bearing hyphae "; 
but Fox and Blaxall by employing a different method of cultivation 
showed that when fructification took place in the presence of air, spores 



TINEA TONSURANS. i 2 8i 

megalosporon. Certain subdivisions of these will be described 
when each species is considered separately. Some even now 
think that the position of the fungus in the hair is a question of 
soil rather than of origin (vide Tinea Ciliae). 

Trichophyton Microsporon,* or Microsporon Audouini, the 

small-spored fungus. This fungus was described by Gruby in 
1843 as the cause of " porrigo decalvans," the old name of Bate- 
man for alopecia areata; hence the importance of his observa- 
tion was overlooked, until Sabouraud showed that Gruby really 
described it as a cause of one kind of ringworm. It is the 
cause of at least ninety per cent, of ringworm in England, fifty- 
two per cent, in Boston, U. S. A., and sixty-five per cent, in 
France — or rather, in Paris, as Dubreuilh and Freche did not 
find it at all in Bordeaux. It is also practically absent in Italy, f 
and North and South Germany, except Hamburg, where it is 
uncommon. It is well known in Barcelona (Fergnani). 

Two closely similar species have been found on animals, one 
by Sabouraud and others on the horse, and one by Bodin on 
the dog, and they have been inoculated on the human subject 
with clinically and microscopically nearly similar results to the 
human species, but they all differ from one another culturally in 
many points. Bodin also has shown that there are two forms 
of microsporon of the horse which produced a scaly and smooth 
form of ringworm in that animal. Sabouraud lays stress upon 
the point that the microsporon is the only one of the ringworm 
fungi which is capable of passing through a complete develop- 
mental cycle with the production of ectospores, while parasitic 
on the human subject. 

" Hence," he says, " it is so extremely contagious among 

like those of the trichophytons were produced, and even chlamydo-spores, 
like trichophyton ectothrix. 

* Mr. George Pernet has been working with me for some years at Uni- 
versity College Hospital, For a long time he examined nearly every 
case of ringworm microscopically, and when thought necessary, cultur- 
ally, and when it is stated that any particular form of fungus is found 
with special clinical features, it is the result of his investigation. His 
paper on 130 cases of ringworm is published in Lancet, October 1, 1898, 
p. 868. See also Pernet, Encyclopedia Medz'ca, vol. xi., 1902. 

f Mibelli has met with one case at Parma due to the microsporon of the 
dog. 

81 



1282 DISEASES OF THE SKIN. 

children, and difficult to cure. It grows throughout the hair 
in a long-jointed mycelium; from this branches pass outwards 
towards the surface of the hair, and fine branches at length 
penetrate the cuticle; on these fine branches when they reach 
the surface of the hair are formed the ectospores^ so that the 
very closely arranged mass of spores seen surrounding the hair 
in cases of microsporon ringworm is entirely made up of ecto- 
spores varying from two to three pi in diameter." 

Colcott Fox denies the accuracy of this description, because 
(a) the hair itself is only invaded after the mosaic begins to 
form or: it; (b) the cuticle is stripped off rapidly at an early 
stage; (c) he can find no proof of Sabouraud's theory. 

The mode in which the fungus gains entrance into the hair 
substance has led to much discussion. The older and more 
generally held view was that the fungus entered at the orifice 
of the hair follicle, penetrated between the shaft and follicle, 
and passed downwards until it reached the softer cells of the 
bulb, and was then carried up by the growth of the hair, the 
mycelium insinuating itself between the hair fibers. This is what 
Balzer calls the theory " du detour " (see Plate IV.). The other, 
or direct, theory is supported by Unna, who says that a short 
distance down the follicle the fungus passes under the cuticle 
of the hair shaft into its substance, and then extends down to 
the bulb and up into the shaft. It is probable, therefore, that 
the fungus may get into the shaft by either route, according to 
circumstances favoring the one or the other. 

Leslie Roberts finds that the fungi have a keratolytic action 
corroding the outer part of the hair shaft, even in a cultivation. 
This view is supported by what is known of onygena equina, a 
horn-destroying fungus, which grows on horn, hoofs, etc., and 
the life-history of which has been worked out by Professor 
Marshall Ward of Cambridge.* 

MacFadyen f finds that the ringworm organism produces a 
proteolytic enzyme which liquefies gelatin rapidly. It is capable 
of acting when greatly diluted, and acts best at or near blood 
heat; it is favored by alkalinity and hindered by acids; it is 
destroyed at a temperature of 212 F., but ordinarily is very 
stable. 

* Royal Society, May 4, 1899; abs. in Nature, 1899, p. 92. 
\ Brit. Med. Jour., September 22, 1894. 



\ 



Plate II] 



TRICHOPHYTON TONSURANS. 
(Ringworm Fungus.) 




Plate IV. 



TRICHOPHYTON TONSURANS. 




M 



\ - 




Fro. 2.— Root-end of hair from Trichophyton Endothrix, showing 



TINEA TONSURANS. 1283 

Waelsch * found that the fungus penetrates the cortex of the 
hair at different distances in rising and descending, but spares 
the bulbs. It also forms a reticulum of filaments round the 
hair. It develops equally well in the deeper horny cells and 
the cells in process of keratinization in the hair follicle. 
Waelsch is of opinion that differences of structure determine 
the differences in the fungus. 

Symptoms. — Microsporon ringworm, f which is the type of the 
disease in England at all events, begins as a red papule round 
a hair, which soon becomes a small, round, well-defined scaly 
patch, pale or grayish-red, but covered with fine w T hite scales. 
It spreads peripherally; and as the fungus gets down into the 
follicle, by the time the patch is the size of a threepenny-piece, 
if not before, the hair shows signs of damaged nutrition. The 
patch continues to enlarge up to the size of a florin, or even 
a crown-piece, seldom larger, preserving its rounded outline, 
unless two or more meet and coalesce into an irregular patch 
with gyrate outline, of almost any size, but with the borders 
always sharply defined. The larger patches are distinctly thick- 
ened and scaly, of a dirty grayish hue, and at first sight bald, 
but close inspection with a lens always shows that the patch 
is covered with stumps of hair, dull and lusterless, bent or 
spirally twisted, sticking out in all directions, instead of having 
a definite " set," and so brittle that if an attempt is made to 
pull them out, many break off at or below the surface. They 
are usually from one-sixteenth to one-eighth of an inch long, 
sometimes a quarter of an inch, and a white sheath, made up 
of spores, extends a short distance up the shaft of a good many 
of the stumps, if the case has not been previously treated. 

When a stump has been soaked sufficiently in liquor potassae, 
B. P. (e. g., half an hour), and placed under the microscope, it 
is seen to be ensheathed by round spores, or conidia, of from 
2 jx to 3 pt closely pressed together in a mosaic. By pressing 
gently on the cover-glass the spores of the sheath may be more 
or less separated, and the hair shaft exposed, and it can then 
be seen that the spores were outside the hair. By further 
soaking and pressing a delicate mycelium, running more or less 

* Archiv f. Derm. u. Syph.. vol. xxxv. (1896), p. 23; abs. in Annales y 
vol. viii. (1897), p. 150. 

f Author's Atlas, Plate XCII., Figs. 3 and 4. 



1284 DISEASES OF THE SKIN. 

parallel with the hair, can be discerned with a high power inside 
the shaft. 

Variations. — In very fair and fine-haired children, instead of 
the hairs sticking up they lie close to the skin, spirally twisted 
like the fibrils of wool, almost matted together, and looking dull 
and thickened, and covered with powdery-looking debris of 
fungus-bearing epithelium, which gives them a white color. 

In the same class of children, when the bulk of the disease 
has been removed, a few pustules may sometimes be seen here 
and there, in and around which, on close inspection, may be 
found some remnants of diseased stumps, which have set up 
the inflammation; but, as a rule, inflammatory signs are in- 
conspicuous in microsporon ringworm. In young infants, 
where the hair is fine and scanty, and in older children, only 
where the hair is thin, there are distinct rings, the disease 
closely resembling tinea circinata. The hair follicles may or 
may not be involved subsequently, but the disease in this form 
seldom gives much trouble, as it is superficial. I have seen 
these rings even in a child of three. 

An important but rather uncommon variation of peladoid 
ringworm, probably of microsporon origin, is what Liveing 
called bald tinea tonsurans, in which the disease commences in 
the ordinary scaly patches, but after a time the hair in one of 
the patches falls out, and the scalp becomes as smooth as in 
alopecia areata, and on the borders of the patch the short, 
characteristic hairs of alopecia areata may frequently be found. 
Curiously enough, when one patch takes on this condition the 
others almost invariably follow suit; but during this transition 
period the bald and scaly patches may be seen simultaneously, 
and these are the cases recorded from time to time as alopecia 
areata, complicated with tinea tonsurans. I have, however, seen 
patches of alopecia areata develop on the head of a child, with 
patches of microsporon ringworm away from the original ring- 
worm, but this is extremely rare. Colcott Fox * has also had 
a case of this kind. When all the patches have become bald the 
history of commencement in scaly patches will be the only 
guide to the mode of origin of the disease, though careful mi- 
croscopical examination of some of the hairs immediately round 
the patch will generally detect the fungous elements. Many 
* Brit. Jour. Derm., vol. xiv. (1902), p. 261. 



TINEA TONSURANS. 12 85 

cases, however, are bald from the first, and some of these occur 
in families where the rest present ringworm in the usual form. 
Pea-sized, smooth, bald spots are seen in some large-spored 
forms in which stumps require to be diligently searched for. In 
a few cases, microsporon has been found. (See also under 
Alopecia Areata, in which instances of epidemics of so-called 
alopecia areata are related.) 

Persistent Scaliness. — Another condition that leads to difficulty 
is where, under treatment, the great bulk of the diseased hairs 
have been removed or fallen out, and the scalp remains per- 
sistently scaly. Such cases are often erroneously considered to 
be no longer infectious, and allowed to mix with other children, 
but the disease is still rampant, and careful examination will 
always find some diseased stumps. 

On the glabrous skin the microsporon may occur alone, or, 
in about twenty per cent. (Pernet), associated with scalp lesions. 

It produces, as a rule, far less actively inflamed lesions than 
the megalosporon. At the same time Sabouraud's statement 
that the lesions are always insignificant is not borne out by 
my experience, for, as a rule, the inflammatory phenomena, 
although mild, are of a decided character, and rings, sometimes 
concentric, are quite as frequent as solid patches. 

It is said never to attack the beard or nails, and on the scalp 
to be exclusively a disease of early childhood, rarely beginning 
after eight years old, never after fourteen, and after the age of 
fifteen is never seen, all adult cases of ringworm of the head 
being large-spored. 

These statements as to age are, in my opinion, too definite 
except as regards adults. I have recently seen a microsporon 
commencing on the scalp of a boy pver fourteen, and another 
in a youth, aet. nineteen, who had contracted it from his sister, 
set. eleven, in whom it had existed for two and a half years. 

Tricophyton Megalosporon Endothrix. So far megalosporon 
endothrix has only been found in the human subject, and, ac- 
cording to Sabouraud, seventy-two per cent, of large-spored 
cases are due to this form, of which there are two species: 
megalosporon endothrix with resistant mycelium (forty-two 
per cent.), and megalosporon endothrix with fragile mycelium 
(thirty per cent.). 



1286 DISEASES OF THE SKIN. 

They have respectively a crateriform and acuminate culture. 
Whether these figures are true for other countries than France 
cannot be stated. 

In both varieties the characteristic features are mycelial 
threads composed of chains of doubly contoured spores. This 
sporulated mycelium is in nearly parallel lines within the hair 
shaft, commencing at the root, running throughout the whole 
length, and branching dichotomously from time to time as it 
grows up the hair shaft, and seldom breaks through to the 
exterior of the hair. 

T. Megalosporon Endothrix with fragile mycelium produces 
la tondante pcladoidc of Sabouraud, the black dot ringworm of 
Aldersmith. The chain formation is indistinct; first, the spores 
are crowded together and of rounded outline, so that in the 
chains a moniliform appearance is produced. These chains 
break up easily during examination, after soaking in potash, 
and thus the moniliform appearance and fragility of the 
mycelium are distinguishing features. (Plate III., Fig. 2.) 

Clinically megalosporon endothrix with fragile mycelium con- 
trasts with microsporon tinea tonsurans in the absence of fine 
white scales (with rare exceptions), the paucity of stumps and 
the patches being less definitely circular. 

At first sight there is an almost smooth baldness, often affect- 
ing a large area from partial coalescence of neighboring patches, 
but the baldness is not like that of alopecia areata, but incom- 
plete, partially broken up by ill-nourished hair, while the small 
balder spots from half an inch in diameter show, on close in- 
spection, some of the stumps broken off level with the surface, 
and only looking like dots; these have no hold on the skin, and 
when drawn out are a sixteenth to a twelfth of an inch long. 
A few project from a sixteenth to an eighth of an inch above the 
surface, but they generally break off if an attempt at epilation is 
made ; still fewer are a quarter or third of an inch long, slightly 
spiral or curved. 

None of them have the white sheath of the microsporon 
stumps, but are swollen, dull, and brittle. There is sometimes 
slight redness and crusting, and at others smooth, bald, de- 
pressed, pea-sized spots, round which it is often difficult to find 
any stumps. 



TINEA TONSURANS. 1287 

Circinate rings on the epidermis are said to precede the hair 
invasion, but they are fugacious and seldom observed, and when 
the hair is attacked these rings disappear. 

There is no age limit on the scalp in this form, adults in rare 
instances being attacked. 

In T. megalosporon endothrix with resistant mycelium, the 
mycelium does not easily break up and the segments are square, 
so that Sabouraud aptly compares it to a ladder. (Fig. 2, 
Plate IV.) 

The clinical appearances are less constant, and while they are 
easily distinguished from microsporon cases they are not very 
distinct from the fragile form. C. Fox relies most on the bald- 
ness being less pronounced and the unequal length of the 
stumps, and there being fewer broken off level with the skin, 
which between the stumps is smooth and apparently normal, but 
■even in the peladoid form, stumps of variable length above the 
surface are to be found as well as the black dots. Microscopi- 
cal examination at least would, therefore, generally be neces- 
sary to decide the point of which the practical importance is not 
very great. 

One form of disseminated ringworm (of Aldersmith) is also 
seen with this fungus. Small groups of stumps, sometimes 
broken off level with the skin, may be scattered about among 
the healthy hair. There may or may not be small bald areas as 
well as these scattered foci. Disseminated ringworm may also 
occur in connection with the microsporon fungus. Endothrix 
is sometimes pyogenic, and may then produce kerion. 

In neglected cases, or in those of very long standing, the great 
bulk of the disease clears up, and there may be no distinctly 
bald or semi-bald patches, but in some places the hair looks 
lusterless and breaks easily, and close inspection alone reveals 
Tiere and there a solitary stump or small collection of broken- 
off hairs, scattered more or less over the whole scalp. Such 
cases require great care for diagnosis and great perseverance 
in treatment. 

T. Megalosporon ectothrix * is of animal origin, though it 
may be transmitted from man to man. Fox estimates the fre- 

* Endo-ectothrix is the more strictly accurate term, for Sabouraud now 
admits what other observers have found, that the fungus, though mainly 
outside, may eventually invade the hair substance. 



1288 DISEASES OF THE SKIN. 

quency of scalp ringworm due to this fungus as " perhaps five 
per cent.," and confirms Sabouraud's dictum that it produces all 
cases of tinea sycosis and tinea unguium. Fox also says that 
it causes more than half the cases of tinea circinata, and reckon- 
ing all sites, half of all large-spored ringworms. This does not 
quite accord with Pernet's estimate of tinea circinata, who, 
as already stated, found that both forms of large-spored to- 
gether only produced half the cases of tinea circinata. 

So far, however, in tinea sycosis we have only found ectothrix, 
and in tinea unguium it is also the rule, but endothrix has been 
found twice by Pernet. (Vide Plate IV., Fig. i.) In another 
private case of his of twenty years' standing, the endothrix was 
proved by culture as well as by the microscope. 

Clinically the appearances vary considerably, but it is often 
pyogenic (i. c, can excite pustular inflammation without the 
intervention of pus cocci); hence it is almost exclusively re- 
sponsible for all the pustular varieties of ringworm, such as 
kerion of the head, tinea sycosis, and what was described by 
Leloir as conglomcrativc pustular folliculitis. This fungus is de- 
rived directly or indirectly from the horse, cat, dog, calf, pig, 
and sheep, etc. It also produces many dry forms of tinea 
circinata, including probably all the cases which sometimes 
cover large areas with complicated patterns,* even when there 
is no vesiculation or pustulation. There is generally, both on 
the scalp and smooth skin, more marked inflammation than is 
usually seen either in microsporon or megalosporon endothrix; 
but in some cases, on the other hand, the inflammation is of 
slight degree. In a lady who contracted T. circinata on the 
nose and cheek there were distinct scaly rings, not more 
marked than on an average microsporon case, while on the 
chest the border of the rings were an eighth of an inch wide 
and looked excoriated. 

Microscopically, the fungus is limited to the intra-follicular 
region, with the possible exception of a few mycelial threads 
which extend a little higher up. It forms a sheath between the 
hair and the follicle, but it may to a slight extent also invade 
both structures, but nearly all of it is attached to the epilated 
hair. 

As Fox describes it the spores are agminated in chains, 
* Vide Author's Atlas, Plate XCIV., Fig. 4, and Danielssen's Plate XX. 



TINEA TONSURANS. 1289 

but the sporulation is less regular than in endothrix, and the 
threads in contact with the root sheath are less completely 
sporulated, longer and smaller than those in contact with the 
hair. In the latter the mycelium is rectilinear and runs parallel 
with the hair, is sometimes fragile and sometimes resistant. 

In all other respects the microscopical appearances vary 
greatly except in the same case, or in cases from the same 
source. Thus the spores may vary from four to twelve ^ 
in length, and about two-thirds of the length in their transverse 
diameter. 

The smallest being thus not larger than many microsporon. 
elements, and although their external position as regards the 
hair would be a guiding point, some observers, like Malcolm 
Morris, contend that this feature is more accidental than vital. 

In ectothrix mycelium with such small spores the dichotomous 
divisions of the mycelium would be guiding points, and in a few 
cases, culture would be the only way to decide the character of 
the fungus. 

The great variability in size and other microscopical appear- 
ances is readily explained, if Sabouraud is correct in saying that 
there are nearly twenty species of ectothrix recognizable by 
culture, etc. Some forms have nucleated giant spores. These 
have been several times observed by Pernet and myself in some 
of my private cases of tinea circinata tropica. (Fig. 93.) 

Kerion may be defined as a pustular folliculitis of the scalp 
excited by the ringworm fungus, chiefly T. megalosporon 
ectothrix. Analogous lesions with a different name may be 
seen both in the beard and glabrous skin. Commencing usually 
with bright red spreading circles, but, according to the 
mothers, sometimes with scaliness, every follicle in the patch 
becomes the seat of a pustule, and the acuteness of the inflam- 
mation and the close aggregation produce a well-defined, con- 
siderably raised, convex patch consisting of pustules on a deep 
red base, the whole mass fluctuating, and bearing a superficial 
resemblance to a carbuncle, for which it is often mistaken, but 
there is no induration round the patch, nor deep purplish red- 
ness. The hairs are loosened in the follicles by the suppuration, 
and are easily withdrawn, and eventually fall out, and thus 
effect a natural cure; after their removal, pressure gives exit 



1 2 go DISEASES OF THE SKIN, 

to a thick glairy mucus, more or less mixed with pus, but there 
is never any slough, though subcutaneous abscesses occasion- 
ally supervene, and in severe cases permanent baldness may 
ensue, and even keloid may result. In a case that came under 
me, enormous comedones, many of them double, studded the 
surface where the kerion had been, hair being quite absent, the 
surface being extensively, and, in places, hypertrophically 
scarred. 

Although the pyogenic ectothrix, chiefly from the horse, Sa- 
bouraud says, occasions most cases of kerion, some observers, 
as Adamson, C. Fox, M. Morris, and Given, have found the 
small-spored fungus in relation with it. Fox and Blaxall have 
five times found the megalosporon endothrix, and Macleod 
has found it also in a typical case. So far that has not been 
my experience, except where it has been produced artificially, 
as sometimes happens with oleate of copper, but even with 
strong irritants it cannot be excited at will. On the other hand, 
Pernet took great pains to trace it to the horse, but never ob- 
tained proof of such a connection, though it seemed probable 
in some cases. 

The granuloma trichophyticum of Majocchi is only a form 
of kerion, either on the scalp or elsewhere, in which the eleva- 
tion of the lesions is greater than usual. Several of the cases 
have been traced to a bovine origin. A separate name is 
superfluous. 

A closely analogous condition to kerion occurs on the 
glabrous skin, and was described by Leloir as " conglomerative 
pustular perifolliculitis." * Sabouraud has proved that it is due 
to trichophyton megalosporon ectothrix, and Leloir's un- 
wieldy title may therefore be dropped, and it might well be called 
kerion of the glabrous skin. It occurs chiefly on the backs of 
the hands and forearms, and occasionally elsewhere, in the form 
of one or two (seldom more) oval or roundish patches from half 
to three inches in diameter, and raised from a line to a quarter 
of an inch. The surface is smooth, or slightly mammillated or 
cribriform, the orifices being filled at first with pus, for the small 
hairs have usually fallen out. 

There are also numerous unruptured superficial pustules. 

* Annates de Derm, et de Syp/i., vol. v. (1884), p. 437, with plates. 



TINEA TONSURANS. 1291 

The orifices enlarge to the size of a hemp seed, and pus exudes 
on pressure. 

In a still further stage a phlegmonous condition supervenes, 
the whole fluctuates to some extent, and often sanious pus can 
be pressed out, and its resemblance to kerion is obvious. 

There is some itching and heat, but no pain or enlargement of 
the neighboring glands, as a rule. Its development is acute, 
and it may reach its acme in a week, and when it heals under 
treatment seldom leaves any permanent scar. It generally oc- 
curs in those who have to do with animals, especially calves, 
such as butchers and drovers.* 

The treatment is the same as for kerion. Press out the pus, 
and if any of the holes are large enough, syringe out with 
carbolic acid lotion one in forty, and rub in an ointment of 
sulphur. 5j, acidi carbolici oss, adipis gj. 

Impetigo contagiosa may supervene as a complication either 
from scratching or from injudicious, irritating treatment in the 
spreading stage, setting up eczematous inflammation, and then 
the pus may accidentally become inoculable. If the impetigo 
contagiosa is not arrested at once, the pus spreads the ring- 
worm in the most disastrous way over the scalp. This is what 
Aldersmith calls " recent pustular ringworm," and is quite dis- 
tinct from kerion. 

A. Giletti f has described a case of primary trychophytiasis 
of the mouth. It affected the lips, buccal mucous membrane, 
and tongue, and clinically closely resembled lichen planus of 
the mouth. He refers to Robinson and Cutler's case, shown 
to the Xew York Dermatological Society. 

Etiology. — Ringworm is indisputably contagious and propa- 
gated by the transference of the fungus elements to the scalp 
or body, either directly from child to child, or through the 

* In the case of a packer observed by Pernet in my clinic (Brit. Jour. 
Derm., vol. xii. (1900), p. 415, and vol. xiii. (igoi), p. 98, the agminated 
folliculitis of the forearm was thought by the patient to have been due 
to unpacking Japanese goods Several fellow-packers had been attacked 
in the same way. Cultivations of the fungus showed it to be trichophyton 
meg. ectothrix. There were no other pustular lesions anywhere, and the 
culture was pure from the first, showing the pyogenic nature of the 
fungus. Pernet could not find fungus in the reeds used by the Japanese 
for packing. 

f Turin, 1895, published by Fodratti and E. Lecco. 



1292 DISEASES OF THE SKIN. 

medium of brush or comb or other contaminated article that 
the diseased and the healthy child have come in contact with. 
The horse, dog, cat, cow, pig, sheep, rabbit, and even birds, are 
also liable to it, and have transmitted it to man, and vice versa, 
but the body is more often affected than the head from this 
source. It is possible that, where many affected children are 
congregated together, the fungus may be conveyed by the air 
alone. 

There is but little difference in the liability of the two sexes. 
In six hundred cases of the scalp there were about six per cent, 
more boys. With regard to age, the youngest cases I have 
met with were nine days for the disease on the scalp and one 
week for the body; in the other direction, practically the liability 
to tinea tonsurans ceases about the age of puberty, and it is 
much more amenable to treatment in children of thirteen or 
fourteen. 

This limit is more definite for microsporon than for megalo- 
sporon. Although I have seen a good many cases in which 
microsporon has begun between fourteen and fifteen years, it is 
certainly uncommon, and I can recall only one case commencing 
as late as nineteen. It is probable, however, that in neglected 
cases it persists indefinitely. 

The two following examples of persistence may have been 
really megalosporon cases, as they came under my notice in 
the 1880 decade; but even if they were, they would be note- 
worthy, as Sabouraud says the large are not so persistent as 
the small spored cases. 

In a woman of twenty the disease had existed from the age 
of ten years, and it was in the disseminated form all over the 
head. 

In a lady, set. eighteen, it had been present ever since she 
was four years old, in the form of several small foci of dis- 
eased stumps scattered about. She had had much skilled treat- 
ment, but it had probably been intermittent. I saw her at long 
intervals for three years, and she was not, therefore, cured until 
she was twenty-one. 

I have several times seen ringworm commence in the nape 
and extend into the scalp of an adult, but without producing 
any apparent change in the nutrition of the hair, but whether 
large or small spored I am unable to say. No case, definitely 



TINEA TONSURANS. 1293 

proved to be microsporon tinea tonsurans, has been recorded 
as commencing in adults, my own case of nineteen years being 
the oldest so far. 

On the other hand, large-spored ringworm commencing on 
adult heads, although rare, has been repeatedly recorded by 
numerous observers. It is generally of the peladoid form due 
to megalosporon endothrix. I can only recall three cases in 
my own practice, one set. thirty-four, another fifty-three, and 
the third fifty-five.* On the other hand, tinea circinata, both 
micro- and megalosporon, may occur at any age, but it is un- 
common after fifty, and is then usually ectothrix. 

Malcolm Morris advanced the opinion that tinea tonsurans 
was more common and obstinate in fair-haired children. It is 
undoubtedly more common in fair children, but simply because 
fair children predominate in this country. In investigating this 
point, the color of the hair and eyes was noticed in five hundred 
children, taken consecutively at the East London Hospital for 
Children; then a record was kept of the same points in four 
hundred cases of ringworm, taking golden-haired, light brown, 
and the few red-haired children together as fair, and the rest as 
dark; it was found that there were 82.4 per cent, fair and 17.6 
per cent, dark, while in ringworm there were 82.6 per cent, fair 
and 17.4 per cent, dark — a curiously identical proportion. I 
have not been able to observe that the disease is more obstinate 
in fair children than dark, but Leslie Roberts says that pig- 
mented hairs resist the keratolytic action of the fungus better 
than unpigmented hair, which would lend some support to the 
theory. 

There is no known constitutional or other condition of the 
patient to be made out that predisposes to ringworm, though 
these is no doubt that some people are more susceptible than 
others, i. e., that their skin or hair follicles offer some special 
advantages for the cultivation of the fungus. No doubt, too, 
it flourishes more readily in badly nourished children; but, on 
the other hand, I have met with it in an extremely developed 
and obstinate form in perfectly healthy children, both fair and 
dark; so that, while it is always right to attend to any defect 
of the general health, I could never convince myself that the 
progress of the disease was materially influenced by such meas- 

* In this case Pernet found endothrix by the microscope and by culture. 



i2 9 4 DISEASES OF THE SKIN. 

ures, and Tilbury Fox's dictum that children with ringworm 
dislike fat, and similar statements, are, I believe, fallacious. 

The reason that ordinary or microsporon ringworm of the 
scalp does not occur in adults, and that the bald form of ring- 
worm is seen in a certain number of children, is, I believe, due 
to the greater resistance of the hair to the invasion of the 
fungus in adults, and in some dark-haired children and others, 
so that, while the fungus may pass down into the follicle and 
interfere with the nutrition of the hair, it does not penetrate the 
shaft. The way in which the fungus attacks the hair, whether 
through the cortex, as microsporon most frequently does, or 
round by the root and then upwards in the shaft, as in megalo- 
sporon, may account for the occasional appearance of the large- 
spored ringworm in adults. That it is not merely a question 
of age is shown by the fact that megalosporon ectothrix ring- 
worm attacks the beard, and there the fungus often penetrates 
into the hair shaft, although it is in the main outside. 

Diagnosis. — There are few diseases of the skin in which 
errors of diagnosis are so frequently made as in ringworm of 
the scalp. Such errors are often most serious in their results 
to a school or other community of children, and bring, there- 
fore, the practitioner into disrepute. To avoid this it is neces- 
sary not only to know the aspect of typical cases — which, indeed, 
the laity themselves can often recognize — but the variations al- 
ready enumerated. It is also necessary to remember that the 
amount of inflammation excited by the fungus is very variable 
and may mask the primary condition, and that familiarity with 
the diseased stumps, under all conditions, is an indispensable 
requirement. In a few doubtful cases the skillful use of the 
microscope can alone decide the question, though if all the 
points to be described be borne in mind, this will rarely be 
absolutely necessary, except to settle whether a case is really 
cured. 

In an ordinary way it may be said that loss of hair on scaly 
patches in the scalp of a child means ringworm, and close 
inspection with a lens in such a case will almost invariably 
detect the characteristic, browsed-off stumps of hair, bent, 
broken, twisted, and sticking out in all directions, or with the 
appearance described as occurring sometimes in fair-haired chil- 
dren, under Microsporon Ringworm. 



TINEA TONSURANS. 1295 

The main naked-eye distinctions between microsporon ring- 
worm and megalosporon ringworm are, in the case of the latter, 
the much smaller number of stumps, many of them broken off 
level with the skin; the scantiness or even absence of scales, 
so that alopecia areata may be simulated; and the outline is 
often less markedly circular and well-defined, and there may 
be some unaffected hairs in the diseased area. The distinction 
between the different forms of megalosporon is of merely 
academic interest, and can seldom be made without microscopi- 
cal, and often cultural, investigations. 

The following differential features refer to microsporon 
ringworm only. 

The diseases which most closely resemble* it are dry sebor- 
rhea of the scalp and psoriasis. 

In seborrhea the scaliness is diffuse, and never in sharply cir- 
cumscribed patches, and though there may be some slight loss 
of hair, it is in the form of general thinning, and there are never 
any broken-off stumps; moreover, in children, simply scurfy 
seborrhea is not so common as in later life, while ringworm 
is practically limited to childhood. 

Psoriasis sometimes offers more difficulties. Of course, if it 
is present in its usual situations, on the elbows and knees, or 
elsewhere on the body, no difficulty ought to arise; but the 
patient's friends do not always spontaneously inform the doctor 
of this, and in a few instances psoriasis is confined to the scalp, 
at all events for some time. The patches are circumscribed 
and scaly, but the scales are more abundant than in ringworm, 
often forming crusts; moreover, loss of hair is the exception, 
not the rule, in psoriasis, and there are never any stumps, but 
great care is required in order to be sure of their absence in 
fair, fine-haired children. 

Eczema cannot be confused with typical cases, but sometimes 
either from scratching or from irritant applications, ringworm 
may present some eczematous characters, and the ringworm 
may be thought to be eczema only. The loss of hair, the cir- 
cumscribed scattered patches, which are unusual in eczema, 
ought to excite suspicion, and close examination will then de- 
tect the short hairs of ringworm. 

The distinction of kerion from carbuncle has alreadv been 
alluded to; and from impetigo contagiosa, even when combined 



1296 DISEASES OF THE SKIN. 

with ringworm, it may be distinguished by kerion being raised 
and sharply defined, and the pustules are always seated round 
the hairs. In any doubtful case the microscope should be re- 
peatedly used. 

Prognosis. — Although every case is curable it is very difficult 
to give a correct answer to the anxious question, " When will 
it be well? " In a very recent case six weeks to three months 
would be a reasonable time for a cure, though even then it is 
not certain. For many chronic cases six months is a short and 
twelve months a fair time, but some cases take longer even in 
the most experienced and skillful hands, and a large proportion 
of the cases reported as cured in a month or six weeks are 
only examples of unskilled observation. 

Sabouraud and some of his followers state that the megalo- 
sporons are more amenable to treatment than the micro- 
sporons. This may be true as a general statement, but its value 
is largely discounted by the fact that many of the most obstinate 
cases I have had to deal with have been large-spored, and 
Aldersmith and others have had a similar experience. 

Treatment. — The theory of this is simple, viz., to destroy the 
fungus which is the cause of the disease; but, though parasiti- 
cides are numerous and sufficiently powerful, it is found in prac- 
tice that while the cure of this disease is very easy, as a rule, 
when the disease is only on the body, where it can be easily got 
at, it is very difficult to cure on the scalp, where the problem 
is how to get the parasiticide deep enough to reach the fungus, 
which often grows down to the very bottom of the follicle. 

Tinea eireinata is generally curable in a week or two by almost 
any of the recognized parasiticides. The scales should be re- 
moved (unless the eruption is on the face) by means of soft 
soap and a piece of wet flannel, and the patch, if in a covered 
part, painted with tincture of iodin, or acetic acid, or sulphurous 
acid; or hyposulphite of soda 5ij to f>j of water may be applied 
on lint covered with oiled silk; an improvement on this is to 
soak the skin first with the hyposulphite of soda solution 3ss 
to %), and then with a tartaric-acid solution gr. xv. to §j. The 
result is the development of nascent sulphur and sulphurous 
acid on the skin itself, and in it, according to the degree of 
soaking with the lotions. Or one of the following ointments 
may be rubbed in three times a day — sulph. sublim. 3ss, 



TINEA TONSURANS. 1297 

acidi carbolici TT^xx, lanolini ovj, ol. olivse oij ; cupri oleatis 
oss, lanolini c. oleo 5J ; hyd. ox. flav. oj, lanolini c. oleo 5j. In 
an infant very weak preparations are sufficient, such as ung. 
hyd. nit. dil., or hyd. amnion, oss, to 5J of lanolin or lard. 

On the other hand, in so-called eczema marginatum, especially 
when contracted in tropical climates, very powerful and pene- 
trating parasiticides are required in some cases, though there 
is no harm in trying milder preparations at first. After thor- 
ough washing with soft soap, the nascent sulphur treatment 
just described should be thoroughly applied under oiled silk. 
In tropical and more obstinate cases Goa powder, or its active 
principle, chrysarobin, is one of the most actively effectual 
remedies; it may be used as an ointment — chrysarobin gr. x 
to oss, lanolin Siij, adip. ov; or a piece of flannel moistened 
with strong acetic acid may be dipped into Goa powder and 
well rubbed on; or half a lemon may be dipped into the powder 
and used in the same way. 

The disagreeable effects detailed while describing the use of 
this drug in psoriasis may ensue, and patients should be warned 
of this possibility, and the remedy should not be resorted to, 
therefore, until milder measures have failed, such as oleate of 
mercury, oleate of copper, and many other remedies mentioned 
in the treatment of scalp ringworm; but in all cases a perfect 
cure should not be hastily inferred from the absence of dis- 
eased appearances, as some living spores may remain in the 
epidermis ready to spring into activity as soon as parasiticide 
remedies have been discontinued, or when the weather or cli- 
mate is warmer, to the disappointment of both patient and 
doctor; every case, therefore, ought to be carefully watched for 
some time, and the slightest return immediately and vigorously 
treated. R. W. Taylor recommends hyd. perchlor. gr. 2, tinct. 
benz. co. Jj, to be painted on daily. 

The treatment of tinea tonsurans remains the opprobrium of 
the dermatologist's art, from the difficulty experienced in carry- 
ing the parasiticide deeply enough into the follicle. As in all 
obstinate diseases, a legion of remedies are put forth as certain 
and speedy cures. I know of only one certain remedy, namely, 
perseverance. The most common source of failure is intermittent 
'treatment; the friends relaxing their efforts, or feebly trying all 
the so-called cures recommended to them by their friends. 
82 



1298 DISEASES OF THE SKIN, 

There is no case which cannot be cured, though too often suc- 
cess is only attained after a long course of treatment, and it 
may happen that when success is in sight the patient is taken 
off to someone else, who reaps the fruits of many months of 
labor and gets all the credit. The consolation lies in the truth 
of the proverb, " Hodie tibi, eras mihi." 

It will serve no good purpose to enumerate all the plans of 
treatment which have been brought forward even in the last 
ten years; a sketch will first be given of the general means to 
adopt for the cure of the disease, and for the prevention of its 
spread, either on the patient himself or to others, and then my 
own experience will be related of the most highly advocated 
remedies or methods of treatment. 

The first thing to do is to cut the hair as closely as possible 
for at least an inch all round the patch, or if there are more 
than one or two patches, it is better to remove the whole of the 
hair, leaving at the most a fringe all round, which, comings 
below the hat or cap, conceals the tonsure and prevents the 
patient from attracting too much attention. Whether the hair 
should be cut as closely as scissors can cut it, or shaved, is 
immaterial, but cutting is more convenient, especially as the 
process has to be repeated every few days. If shaving be em- 
ployed Calvert's carbolized soap should be used, and the brush 
cleansed with carbolic lotion, 1 in 20, otherwise the shaving 
brush may disseminate the disease, or a fresh pad of absorbent 
wool can be used each time, instead of a brush. The object 
of removing the hair is twofold: it enables the diseased area 
to be more easily got at, and also any fresh focus of infection 
can be at once detected, when prompt treatment may effect a 
speedy cure, for when the hair is long the early lesions often 
remain undiscovered until the fungus has got deeply into the 
follicle, and is difficult to reach. 

The parasiticide should be applied, not only on, but round the 
patch, and great care must be taken to get it into the tissues 
as deeply as possible. If it is a lotion it should be dabbed on 
or brushed in, for some minutes; if an ointment or oily fluid 
it should be well rubbed in, at least twice a day. With regard 
to washing, some difference of opinion has been expressed. 
Aldersmith and Malcolm Morris consider that when ointments" 
are used washing should be done not more than once a week,, 



TINEA TONSURANS. 1299 

as it removes the ointment and prevents it penetrating so 
deeply. The chief objection, in my opinion, is, that if care be 
not exercised in drying the head, the disease may be transferred 
by the towel from one part of the head to another. The head 
should be dried, therefore, by pressure, and not rubbing with the 
towel. Thymol or other parasiticide soaps have a slight ad- 
vantage as detergents. Morris recommends cleansing with 
spirit and ether to dissolve fatty substances and dehydrate the 
tissues, and thinks that water favors the development and 
spread of the fungus. 

When the child is old enough — that is, over six years — epila- 
tion is a valuable adjunct; it should not be done until after 
treatment has been employed, either to loosen the hairs or to 
deaden sensibility. The latter may be effected by glycerin of 
carbolic acid, or cocain ten per cent, in lanolin, the hairs may 
be loosened generally by oleate of copper, or soaking with solu- 
tion of salicylic acid gr. v. in ether §j, and other means to be 
enumerated. The epilation should be performed systematically; 
a square quarter of an inch or more should be cleared each day, 
according to the child's endurance. 

When the child is eleven or twelve, and the part has been 
thoroughly numbed, Duckworth's large epilation forceps may 
be used at first, and a considerable area quickly cleared. Large 
numbers of hairs break off doubtless, but many are removed; 
the process is painful, and this plan is therefore only suitable 
for a small number of cases. When the hairs that have been 
broken have grown up again they must be attacked individually 
with a finer pair of forceps, and pulled out carefully in the 
direction of their set; with care, vast numbers of hairs may be 
removed, but there will always be some too brittle for this plan 
to be completely efficacious. The parasiticide should always be 
applied immediately after epilation. When the child is young 
or nervous this valuable adjunct has to be dispensed with. 

To prevent the disease spreading on the child itself all scales 
should be removed by soft soap, preferably carbolized, and the 
head should not be brushed, as that sows the spores broadcast 
over the scalp; on the whole, too, oily preparations are prefera- 
ble to watery ones, to prevent the spores being carried from 
one part of the head to another, or from contaminating the 
atmosphere; for this purpose, carbolized oil one in twenty 



i3°° TINEA TONSURANS. 

should be rubbed over the whole of the scalp, while the stronger 
application is used for the patches themselves. The lining of 
all hats and caps that have been worn should be taken out and 
burned, and tissue paper put in their place, and this can be 
thrown away daily; the caps or hats themselves should be re- 
newed at least every month, while the stuff caps which have to 
be worn continually should be thrown away even more fre- 
quently. The child should be isolated from others as far as 
possible, but where this is impossible the patient must constantly 
wear a light cap of some kind lined with tissue or oiled paper, 
which must be changed daily, and no close contact with other 
children allowed. The healthy children's heads should be 
washed two or three times a week, and of course the diseased 
and healthy should not be allowed to use the same comb, 
brushes, or towels. When these measures have been rigidly 
carried out I have never known the disease spread to others, 
even when they have lived in the same room. The parasiticide 
applications, and the best means of making them penetrate suffi- 
ciently deep, remain to be considered. 

The introduction of lanolin as a basis instead of lard or petro- 
leum fats is an improvement for ointments, but it is too sticky 
by itself, and it is better, therefore, to add a fourth part of olive, 
almond, or heavy paraffin oil, or to combine it with lard as 3v 
to lanolin 5iij. The base I use most is lanolin 5v, parolien (a 
heavy paraffin oil) oiij. This mixture of oil and lanolin is 
therefore intended to make up the ounce in all the formulae of 
parasiticide ointments; other solvents, each advocated by its 
author as the plan, have also been suggested, and are of certain 
utility, but fall far short of infallibility. 

These solvents are — chloroform, ether, benzol, turpentine, 
potash, and soft soap; in one of these menstrua the parasiticide 
is dissolved, and applied in the manner considered most suitable; 
all are successful in some cases, none are so in all, and unfor- 
tunately, we have no data on which we can rely, which enable 
us to predict whether any particular remedy, will or will not 
succeed. One great source of fallacy is this, that when the 
disease is recent most of the proposed methods are successful, 
and likewise when the case has been worried at for months with 
various parasiticides, and then goes to a fresh doctor, his favor- 
ite formula will probably score another success, and impress his 



TINEA TONSURANS. 1301 

mind with its wonderful efficacy. Xot a few old women's and 
barbers' nostrums have obtained their reputation in this way, 
but their failures are never recorded. Pessimistic as these state- 
ments appear, they are intended not to discourage the practi- 
tioner, but to point out that the road to success is to be sought, 
not in this or that formula, but in perseverance with the various 
measures indicated, coupled with the employment of parasiti- 
cides, which are not to be hastily changed if there is any prog- 
ress at all, such progress being looked for month by month 
rather than week by week. For some years past I have en- 
deavored to test almost every method advocated by anyone 
of reputation, or in which the method itself offered anything 
like a chance of success. Twenty or thirty consecutive cases 
have been put on the treatment for at least three months, and 
then an endeavor made to form an opinion of its merits; the 
matter, however, is too complicated to allow of anything more 
than a statement of the impression made on my mind by it, but 
where good authorities have come to a different conclusion their 
views will be stated. The ground will be cleared by first de- 
scribing the treatment that will suit simple cases. 

In infants of a few weeks or months old the disease is almost 
as easily cured as tinea circinata; a good formula is sulphur 5j, 
acid carbolic 5ss, lanolin c. oleo 5], or ung. hyd. oxid. flav. 3j to 
§j; the sulphurous acid or hyposulphite of soda lotions previ- 
ously mentioned, if continuously applied, or almost any of the 
remedies to be presently described, diluted according to the 
age of the patient, will effect a cure, remembering always to 
keep on the safe side, as the skin of young infants is easily 
excited to intense suppurative inflammation. If one of these 
parasiticides is rubbed in night and morning, or if lotions are 
applied continuously under oiled silk, success will generally 
follow in a month or two, or even less; if the child is under 
twelve months epilation is unnecessary, and, indeed, impossible. 
In older children, in recent cases, one of the best applications 
to cut short the disease is Coster's paint (iodin oij, light oil of 
wood tar 3vj, the bottle to be shaken before using). It should 
be firmly applied with a stiff brush; a black crust forms after 
two or three days, and this should be removed with the forceps, 
not waiting until it shells off of itself: the part is then to be 
well rubbed with soft soap and flannel, and the paint again 



1302 



DISEASES OF THE SKIN. 



applied. Two or three applications are almost infallible before 
the hairs are visibly affected, and even after this it is a very 
useful remedy, but not suitable for children under four years 
old. Aldersmith prefers oil of cade, and Morrant Baker 
creasote, to the light oil of wood tar; they are all equally 
efficacious, but the oil of cade preparation has the advantage of 
being thicker. I attach great importance to tearing off the 
crust, as it brings with it more fungus and diseased hairs than 
if it is allowed to separate spontaneously. For recent cases 
blistering is also useful, either with liquor epispasticus or 
glacial acetic acid, as Aldersmith suggested, the last with the 
addition of hyd. perchlor. gr. 4 to the ounce. These powerful 
applications should not be used on strumous children, nor on 
those under six years old, and it is always wise to do a very 
small area at a time, as it is never quite certain how much 
inflammation will be excited, and a permanently bald patch is 
a perpetual memorial to the imprudence of the practitioner. 
This caution is applicable to all strong remedies, which should 
never be used without preliminary investigation of the child's 
susceptibility. The crust formed by the acetic acid should be 
removed in two or three days with forceps, and weak parasiti- 
cides used for a week before again applying the acetic acid; this 
plan may be used at intervals during the course of other treat- 
ment, but as it is painful it has a very limited application. 
Formalin is one of the remedies put forward as effecting a cer- 
tain cure in a few weeks, in which the above caution is needed. 
I have seen severe scarring produced by its injudicious use. If 
used at all, a dilution of one of the usual strength to ten of 
water should be applied and the strength gradually increased. 
A. Salter, its greatest advocate, used the usual forty per cent, 
solution, and claimed for it more good and less evil than Aider- 
smith, Morris, and others could get, and it is very painful. A 
remedy that I regard as most valuable before epilating, and for 
a large proportion of cases of all kinds, is oleate of copper, of 
which Shoemaker and Le Sieur Weir were the earliest and 
strongest advocates; as a rule, a dram of the pure oleate to one 
ounce, in the form of ointment, is most generally useful; and 
where the patient is tolerant, the strength may be gradually 
increased up to 3iv to the ounce; and I have used equal parts. 
In many cases, under its use the diseased hairs drop out, and 



TINEA TONSURANS. 1303 

leave the part bald and smooth; and even where this is not the 
case, epilation is generally much facilitated, the majority of the 
hairs coming out entire and with little pain. In a large number 
of cases a thorough and satisfactory cure may be effected by its 
persevering employment, but, like everything else, it fails com- 
pletely in some cases. 

Occasionally a mild kerion is produced by it which is advan- 
tageous, but it cannot be produced at will. I often add 10 to 
20 grs. of chrysarobin to the §j of ointment. It increases its 
efficacy, but has the usual drawbacks of dyeing the hair, exciting 
erythema, etc. Five per cent, of pure mercuric oleate is some- 
times added with advantage, and some, like Aldersmith, advo- 
cate stronger proportions up to thirty-three per cent, of mer- 
curic oleate alone. It should not be used over a very large area 
for fear of mercurialization. 

Chrysarobin has also been used in many combinations. 
Hutchinson's formula is chrysarobin 3j, hydrarg. ammon. gr. 
x:x, liq. carbonis deterg. TTLx, lanolin 3j, adipis recent. 5vj. 
Unna's formula is chrysarobin 5 parts, salicylic acid 2 parts, 
ichthyol 5 parts, vaselin 88 parts, rubbed in vigorously twice 
a day, and covered with gutta-percha tissue, and the adjacent 
more hairy parts covered with a zinc-gelatin paste. He claims 
to get a cure in a month, but his are mostly large-spored cases. 
The treatment is too severe unless it can be carried out under 
the closest supervision, and is not suited to out-patient practice 
in my experience. 

Morris rubs in chrysarobin ointment (presumably the B. P., 
20 grs. to the oz.) daily for ten minutes, until a red halo is 
visible, then applies a boric acid or other mild ointment until 
the redness has disappeared, and then resumes the chrysarobin 
until the inflammation has again appeared, which takes longer 
than at first. After three such cycles, if marked improvement 
has not occurred, he tries sulphur, mercury, or iodin. Duhring 
also advocates chrysarobin. At one time I used it extensively, 
but gave it up on account of the frequency of the erythema, 
swelling, and conjunctivitis produced, as well as the yellow 
staining (turning an indelible purple after washing) of linen 
and the hair, while the results were not striking enough to com- 
pensate. As, however, its penetration is undoubted, I have 
tried to get the good without the evil, and have succeeded fairly 



I3°4 



DISEASES OF THE SKIN. 



by not using more than 20 grs. to the oz., by not using it over 
very large areas at a time, and by not using it on the anterior 
portion of the scalp, so as not to excite conjunctivitis; and not 
to use soap, so that the staining is yellow instead of purple. 

In combination with oleate of copper I have sometimes 
traced the staining of the diseased stump almost to the end of 
the root. 

As the main aim is to produce penetration of the parasiticide 
I have devised the following plan: Two solutions are prepared. 
No. 1 is pot. iodatis oij, acid, acetici fort. 5ij, aq. destil. §iv. 
No. 2 is pot. iodidi oij, aq. destil. §iv. 

The affected part of the scalp must be shaved (clipping is not 
sufficient) once a week. The scalp is then soaked with No. 1 
solution with a pledget of lint dabbed on for three or four 
minutes, then while still wet No. 2 is similarly applied. The 
result is the formation of nascent iodin in the skin. Pernet has 
several times found iodin staining at the bottom of the hair 
root. When the epidermis begins to loosen the process of 
separation should be accelerated with forceps and the treatment 
renewed. Great improvement results in most cases, in some 
it has failed, possibly from imperfect application. In a few also 
it was found to be painful, for, as is well known, some people 
are very sensitive to iodin applications, while others bear them 
without inconvenience. 

Jamieson recommends the following mode of treating ring- 
worm of the scalp: 

(1) Keep the hair shaved or close cut during the entire period 
of treatment. (2) Keep the scalp clean by washing vigorously 
twice daily with a fluid superfatted potash soap. (3) The most 
efficacious application he has found to be precipitated sulphur, 
3j ; salicylic acid, /?-naphthol, and ammoniated mercury, each 
gr. x; and lanolin, §j. This ointment is to be rubbed in for 
ten minutes slowly and carefully twice a day. 

Another good plan, but more frequently painful than the 
nascent iodin, is to soak the skin first with acetic acid solution 
oij to §iv of water, and then paint on tincture of iodin. 

'Salicylic acid is another drug, with many friends, either as 
an ointment oj or 3ij to §j, or as a lotion gr. 20 to 60 to the 5J 
of spirit, ether, or chloroform; both are remedies of some value. 
I have also tried salicylic acid plaster, which is useful in some 



TINEA TONSURANS. 1305 

cases, and facilitates epilation. After many trials, the follow- 
ing method has been more successful in my hands than any 
other. The head is shaved, not clipped, over the affected region, 
and for at least three-quarters of an inch beyond the patch. 
Then salicylic collodion (consisting of salicylic acid gr. 10, col- 
lodion 5j) is painted daily for a week, on and beyond the patch. 
At the end of a week the thick skin formed by the collodion 
is lifted off by insinuating one blade of the epilation forceps 
under the skin and gradually lifting up a portion. This is re- 
peated in various directions until the skin is cleared off, and 
then the scalp is again shaved, and the salicylic collodion re- 
applied for another week. The advantages are that, with this 
artificial skin on, the patient is no longer a source of infection, 
the air is excluded, and as the fungus is aerobic, its develop- 
ment is hindered. The salicylic acid loosens the epidermis, and 
also the hairs, so that when the collodion is lifted off enormous 
numbers of stumps can be seen to be adhering to the under 
surface, and the diseased area is eventually cleared of them. 
The disadvantage is that the removal of the collodion is some- 
what painful, so that it is inapplicable to very young children, 
but there are few over seven years of age for whom it cannot 
be used. If the skin is very adherent at the end of a week, a day 
or two longer may be given; if any excoriation is accidentally 
produced, boric ointment should be applied until the skin is 
sound before renewing the collodion. 

The principle of excluding air is one extensively adopted 
since Vidal showed that the fungus is aerobic. Vidal himself 
cleaned the head with turpentine, then painted on tincture of 
iodin, and next smeared on iodized vaselin and covered it with 
laminated gutta-percha. Besnier directs the following: Epilate 
all round the patch, curette off the scales and stumps, wash it 
with alcohol with five per cent, chloroform and one per cent, 
boric acid, again curette, and epilate, then dab it with a per- 
chlorid of mercury solution gr. 1-2 to the §j and five grains of 
glacial acetic acid, and finally seal it over with emplastrum Vigo. 

For a limited class of cases croton oil is recommended by 
Cottle, Aldersmith, and others, and is a most valuable and cer- 
tain remedy for suitable cases, such as chronic ones of limited 
area, and for the isolated and small groups of diseased hairs in 
disseminated ringworm; indeed, for the last form it is often 



1306 DISEASES OF THE SKIN. 

almost the only resort left, and will cure the most obstinate 
cases. A drop of the pure oil is put into the mouth of each 
follicle by means of a needle, preferably a fine crochet needle; 
or, if there are a large number of diseased hairs, a fine hypo- 
dermic syringe may be used. In twenty-four hours a pustule is 
formed round the hair, which can be removed entire — an im- 
possibility without some such loosening process, as the hairs 
are so permeated with fungus as to be utterly rotten, and 
break off within their follicle. The hair is not restored, but the 
loss is not perceptible when the hair grows round it, unless 
several hairs close together are destroyed. Electrolysis will 
also effect the same end, but it is a tedious process for the 
operator, and will rarely be borne by children under twelve 
years old, or even older. Croton oil should never be used for 
strumous children, or for any who are less than six years old, 
and should be applied very cautiously at first, and never for 
more than a square half-inch at a time. In a limited patch, 
where it is necessary to cure in a short time — c. g., to prevent 
the loss of a presentation to a public school — the quickest way 
is to produce a mild pustular folliculitis or artificial kerion, and 
the loosened hairs can then be easily removed. To do this a 
liniment of one part of croton oil to three of olive oil may be 
rubbed in, and if this fails to produce pustulation the strength 
may be gradually increased until the desired effect is reached, 
the pure oil being sometimes required. If well managed the 
hair is sure to grow over the diseased part, taking a long or 
short time according to the severity of the inflammation excited. 
Feulard utterly condemned croton oil, and says epilation should 
be employed instead; but it is only as a necessary preliminary 
to epilation that it should be used. In disseminated ringworm 
the hairs are so permeated by the fungus that they break off 
with very slight traction, unless they are previously loosened 
by suppuration or electrolysis. When, in the treatment of ring- 
worm, either from the sensitiveness of the child or from using 
too strong a preparation, a serous or pustular dermatitis is 
produced, the contagium of impetigo contagiosa may be de- 
posited, and the condition called by Aldersmith impetiginous 
ringworm set up. In the simple inflammation boric acid oint- 
ment must be 3j to the 5j will soon repair the damage, but the 
treatment must be prompt, or the secretion in a recent case will 



TINEA TONSURANS. 1307 

rapidly spread the infection to the neighboring parts. In the 
impetiginous condition the disease should be treated as if it 
were a simple impetigo contagiosa; the crust must be softened 
with carbolized oil and removed, and the diseased area kept 
well covered with the ammoniated mercury ointment. The im- 
petigo part will soon be cured, and the ringworm must then be 
attacked with the ordinary remedies, but of a weaker character. 

Kerion, to a great extent, cures itself, and most authors sug- 
gest very mild measures, such as lead, watery boric acid lotion, 
equal parts of sulphurous acid and water, hyposulphite of soda 
lotion, or boro-glycerid, one to two of water, applied on lint 
under oiled silk; but I prefer sulphur 3j, acid carbolic oss, 
adipis q], removing the loose hairs, and I have had such uni- 
formly good results that I never use anything else. However 
much kerion tumors fluctuate and appear inflamed, they never 
require incision; the dilated follicles, after removing the hairs, 
always allow sufficient exit for the fluid, which is more glairy 
than purulent. The process should be brought to an end as 
soon as possible, as, although self-curative, it is often at the ex- 
pense of the life of the follicle, and permanent baldness results. 

The question arises, How should progress be judged of? The 
only real criterion is a diminution of the number of diseased 
stumps, and no case is safe until they have completely disap- 
peared. The uniform growth of fine downy hair over the de- 
nuded patch, which develops into strong, healthy hair, subse- 
quently takes place; but, even though the new hair may have 
apparently grown all over the patch, the cure must not be as- 
sumed unless careful and repeated search has failed to find a 
single diseased stump, and where there is any doubt as to their 
condition the microscope must be employed. Persistent scali- 
ness is often regarded as only a sequela of ringworm, and 
practitioners sometimes write to the journals, saying that they 
have cured the ringworm; but how can they get rid of the 
scaliness? This is an error; persistent scaliness in patches al- 
ways means that the disease is not yet cured, and careful search 
with a lens will always establish the presence of diseased hairs. 
Even when repeated and skilled search has failed to find such 
stumps, and the hair has grown evenly all over the patch, and 
there is no longer scaliness, there is one precaution which, if 
omitted, may lead to disappointment, viz., that after apparent 



i 3 o8 DISEASES OF THE SKIN. 

cure a weak parasiticide, such as hyd. perchlor. gr. 3 to lanolin 
c. oleo §j, should be rubbed in two or three times a week for 
two or three months. For this reason children should not be 
sent back to school as soon as they appear well, as the bi-weekly 
treatment is scarcely ever carried out there, and it is very diffi- 
cult to convince parents even of the value and necessity of this 
extra precaution. • 

Onychomycosis. For the treatment of ringworm of the nails, 
one of the many proposed plans is to scrape the affected nail 
thoroughly, and then apply sulphurous acid or the hyposulphite 
of soda oij to the ounce of water, on lint covered with oiled 
silk. This plan is good, but the best in my hands has been 
the treatment recommended by Harrison of Bristol for tinea 
tonsurans. Two solutions are prepared. No. 1 consists of 
liquor potassae and aquae destillatae aa ^ss, pot. iodid. oss; No. 2 
solution consists of hyd. perchlor. gr. 4, spir. vini rect., aq. dest. 
aa §ss. The affected nail should be well scraped, then No. 1 
solution applied on lint under oiled silk for fifteen minutes; 
then No. 2 solution is to be immediately applied on lint under 
oiled silk for twenty-four hours, when the nail is again to be 
scraped, washed, and the process repeated. In this way I have 
obtained cures in cases of very long standing. When the skin 
begins to peel, and the finger becomes tender, hyposulphite of 
soda §j ad aq. 5 vn J ma V De used until the skin has become 
thicker again. The same treatment for the scalp requires great 
care. I have seen most disastrous sloughing from its careless 
application. It must be remembered, as No. 1 solution evapo- 
rates, the cautic potash is becoming stronger every minute, and 
a powerful caustic solution is produced. Unless, therefore, the 
medical man can superintend the treatment himself it is better 
not to trust such a potent remedy in inexperienced hands. But 
for the nails it is most satisfactory. 

The nascent iodin treatment as described under Tinea Ton- 
surans is very efficacious, and less likely to make the finger sore, 
but stains the nails. Sabouraud's treatment is to apply con- 
stantly a pad of absorbent cotton soaked in a solution of iodin 
and covered with an india-rubber finger stall. The solution con- 
sists of iodin 1 gram, iodid of potassium 2 grams, distilled water 
1 liter. 



TINEA CIRCINATA. 1309 



TINEA CIRCINATA.* 

Symnyms. — Herpes circinatus; Ringworm of the body; Fr., 
Herpes circine; Trichophytie circinee. 

This is a very common form of the affection, either alone or 
in combination with one or other variety. In my clinic it occurs 
alone in two per cent, of all cases of skin disease, and there 
are many more associated with tinea tonsurans. 

It may be caused by the microsporon or the megalosporon, 
and as far as my clinic is concerned, Pernet found that in chil- 
dren the large- and small-spored cases were in about equal 
numbers, while Sabouraud's statement, that tinea circinata was 
nearly always due to megalosporon, was only true for adults. 

Inasmuch as microsporon of the scalp is as ten to one of 
megalosporon, as is natural, where both the scalp and skin 
were involved the absolute majority were due to microsporon. 

Taking, therefore, all cases on the glabrous skin, whether 
with or without ringworm elsewhere, the most common form 
of tinea circinata in this country is due to microsporon, and, 
as a whole, the inflammatory phenomena are of slight degree. 

The Microsporon form may occur in rings or solid patches. 
The ring begins as a small, pale red, circular, well-defined, 
slightly raised spot, which soon becomes scaly and spreads 
peripherally, clearing up pari passu in the center, thus forming 
a ring, the raised border of which is usually papular and slightly 
scaly. The ring continues to increase in diameter, but without 
thickening of the border, until it has attained to the size of 
a shilling to a crown-piece, and when it has attained to its full 
size either remains stationary, or, the process of involution 
outstepping that of evolution, the ring thins, then gets broken, 
and finally the fragments also disappear, and the process is 
thus spontaneously terminated as far as that ring is concerned. 
It is common, however, for other rings to form ; and if they are 
near each other, they coalesce, the rings being broken at their 
point of contact, and a gyrate figure is produced, inclosing 
sometimes a very large area. There is no attempt at sym- 

* Author's Atlas, Plate XLIV. Fig. 1, with concentric rings, is probably 
microsporon. Figs. 2 and 3 are megalosporon, and so probably is Fig. 4. 



1310 



DISEASES OF THE SKIN. 



metry or any regular arrangement of the rings, but they are 
more common on exposed parts, such as the face, neck, back 
of the hands, etc. There may be slight itching or no subjective 
symptoms at all, and the duration may be days, weeks, or 
months, when untreated. 

The solid patch is pale red, brannily scaly, and enlarges 
peripherally, but does not clear up in the center. Usually cir- 
cular and well-defined, it seldom attains to more than one inch 




Fig. 91. — Tinea Circinata (Microsporon). Zeiss D. D. 10 in. 
tube, and reduced 4. 



across; it is sometimes irregularly shaped, and the parasitic 
nature may not be suspected unless more typical lesions are 
present. The border, however, is always well defined, and the 
small number and usually unilateral distribution should sug- 
gest microscopic examination. 

Sabouraud at first said that microsporon on the glabrous 
skin only caused scurfy spots without redness; but he has modi- 
fied his views since, and in my experience these are less common 
than the above description of cases, and very decided inflam- 
mation occurs sometimes. 

A woman whose child had typical microsporon ringworm 
on the scalp came to University College Hospital with three 
half-inch solid patches, very distinctly raised, bright red and 
scaly in the center, simulating psoriasis with the crust rubbed 



TINEA CIRC IN ATA. 



1311 



off; Pernet found the microsporon fungus. In another micro- 
sporon case with rings, he traced it to a kitten. 

Concentric Rings. This is rather a rare variation. Unna * 
records a case of three, and Arning f one of four, concentric 
rings on the limbs, most commonly at the border of the hair 
















•:*£'. J>~ 




Fig. 92. — Trichophyton megalosporon. 
From an oval patch of tinea circinata on the wrist. Zeiss D. D. 10 in. tube. 

at the nape. In one case with three and another with two 
rings Pernet found the microsporon form, and Bodin traced 
another to the horse microsporon; but whether they are all 
small-spored I cannot say. In a case I saw at the East London 
Hospital for Children, concentric rings and gyrations formed 

* Viertelj. f. Derm. u. Syph., vol. vii. 

f Ibid., vol. x. p. 98, with photograph; also Plate XCIV., Figs. 1 to 4 of 
my Atlas. Figs. 2 and 3 were probably large-spored. 



1312 



DISEASES OF THE SKIN. 



the most complicated patterns nearly all over the trunk * of 
a baby, but the plurality of fungi was not then known, and 
probably it was large-spored. 

In megalosporon cases the rings are larger than those above 
described, or the borders more projecting, and the inflammatory 




Fig. 93- — Tinea cruris, contracted in South Africa. Zeiss D. D. 10 in. tube. 

phenomena more marked, so that there may be more scaling or 
crusting, and the border or even the whole patch may be vesicu- 
lar or even pustular instead of papular; and, speaking generally, 
the more marked the inflammation the more certainly it is due 
to megalosporon, and if pustular, it is almost sure to be an 

* Plate XX., Danielssen's " Vegetable Parasitic Diseases of the Skin,'' 
represents a similar condition, but not quite so elaborate as my case. 



TINEA CIRCINATA. 13 13 

ectothrix of animal origin. The extreme form is described 
under Kerion. Occasionally microsporon may show marked 
signs of inflammation in the patches, but never pustulation. 

Tinea Cruris seu Axillaris,* as the name implies, affects the 
fork and axillae, and is a form of megalosporon which used to 
be called eczema marginatum. 

In these positions the constant warmth and moisture favor 
the growth of the fungus, and the inflammation produced is 
often much more pronounced than that in tinea circinata else- 
where. The primary rings spread rapidly, and soon coalesce, 
forming pigmented areas inclosed by festooned, papulo-scaly 
borders. The limits of the disease may extend almost down 
to the knee, and up to the umbilicus, between and over the 
nates, and up to the sacrum. The border is distinctly raised, 
often notably thickened, much broader than ordinary tinea 
circinata, with thick scales or even crusts from eczematous exu- 
dation, and there is usually considerable irritation. Sometimes 
fresh rings in large numbers form within the festooned in- 
closure, and in any case there is but little tendency to spontane- 
ous recovery. The disease is seen in its most aggravated and 
obstinate form in hot climates, where it is much more common 
than here, and local names, such as Indian, Chinese, or Burmese 
ringworm and " dhobie itch," have been given to it; but no real 
clinical difference has been established between the tropical 
and temperate zone forms of the affection, except that the in- 
flammation may be deeper and more severe and obstinate. The 
tropical disease called tinea imbricata, or Tokelau ringworm, 
is a separate affection. 

I have had a large number of cases of tinea tropica, chiefly 
cruris, from all parts of the world. Pernet has examined many 
of them, and has found that microscopically they varied in ap- 
pearance, but it was common to find very long slender my- 
celium, dichotomously branching, but often plain or only show- 
ing short segmentation here and there. In other cases sporu- 
lation was a strong feature, the segments or spores varying in 
shape and size, but sometimes they were round. Cultures were 
made on maltose agar, and they varied considerably. A case 
of dhobie itch had a pink culture. He came to the conclusion 
* Author's Atlas, Plate XCIII., an extensive case. 
83 



I3 i4 DISEASES OF THE SKIN. 

that they were all large-spored, but probably of different 
varieties. 

Schiff showed a case of a child with tinea cruris and capitis 
at the Dermatological Society of Vienna; and Waelsch, from 
culture experiments on two cases, regards the fungus of the 
head and groin as essentially the same and identical with the 
third form of Krai, who in three cases found all three culturally 
different.* 

Tropical tinea circinata may occur on any part of the body, 
chiefly the extremities. Unless recognized early and treated 




Fig. 94. — Mycelium from tropical Indian tinea circinata on outer border 
of foot, of three years' duration. It apparently went away for a 
year. Zeiss D. D. 10 in. tube. Private Notes, H. 342. 

vigorously it may last for years. I have met with cases of ten 
years' duration and the diagnosis is often difficult, as it may die 
away in the cold weather and reappear when it is hot. 

D. Moukhtar f of Constantinople has called attention to the 
occurrence occasionally on the palms and soles of tinea cir- 
cinata, where it is very likely to take a vesicular form at first, 
and when, later on, the epidermis gives way, it spreads with a 
raised collar of the horny layer, which may lead to an error 
of diagnosis. Several cases have been treated in the dry stage 

* Neumann's Atlas, Plate LXIX., and Sydenham Society's, Plate 
XXXVI., are also good examples. 

f Annates de Derm, et de Syph., vol. iii. 1892 (several communications). 
See also Fig. 42, vol. ii., La Prat. Derm., p. 281. 



TINEA BARBM. 1315 

for the later palmar syphilid, while in the earlier vesicular stage 
it is very like a sweat eczema. The vesicular form would be 
extremely like dermatitis repens. Mansuroff's * case of der- 
matomycosis circumscripta mantis appears to be an instance of this 
tinea circinata palmse. Microscopic examination would be de- 
cisive if the tinea were thought of. It is probably due to a 
megalosporon, but the point has not been investigated. 

The treatment of tinea circinata is given with that for tinea 
tonsurans. 

Herpes tonsurans maculosus et squamosus of Hebra and 
Kaposi is the disease described in this work as pityriasis rosea 
(p. 405), and is not dependent on the ringworm fungus. 

TINEA BARBAE. 

Synonyms. — Tinea sycosis; Hyphogenic sycosis; Sycosis para- 
sitica; Mentagra parasitica; Parasitic sycosis; Ringworm 
of the beard; Barber's itch; Fr., Sycosis parasitaire; 
Trichophytie sycosique; Ger., parasitare Bartfinne. 

Definition. — Folliculitis of the hairy parts of the face, excited 
by the trichophyton tonsurans. 

Ringworm of the beard is generally described as a very rare 
affection, but this is only true of the more severe or kerion 
forms, minor degrees of it, corresponding with tinea circinata, 
being not at all rare in my experience, but their nature is often 
overlooked. 

Symptoms. — The disease begins as an itching, red, round, 
slightly scaly spot, which may enlarge and form a ring with 
a clear center, or remain as a scaly, well-defined patch. The 
border is distinctly raised, and may be papular, papulo-vesicular, 
or slightly pustular, i. e., a few of the papules may have a pus- 
tular point. Other patches usually soon form, and there are 
generally some hair-pierced pustules, either in or beyond the 
scaly patches. It is in this form that the disease usually pre- 
sents itself among the better classes, who shave daily and prac- 
tice frequent ablutions. 

In the more severe, or what may be called the kerion form, 

* International Atlas, Plate XV. 



1316 DISEASES OF THE SKIN. 

although the disease may begin in the same way, the inflamma- 
tion soon becomes more severe, as in the following typical 
example. 

A robust man, aet. thirty, with reddish-brown beard, stated 
that the disease began as a red ring, the size of a sixpence, 
on the side of the lower jaw, after being shaved at a barber's. 
The ring was soon followed by a scaly patch just above it. 
Shaving led to a watery discharge, the patches spread periph- 
erally, and the more he shaved the more discharge there was, 
which soon became partly thick and glairy, partly " mattery." 
When seen, two months from the onset, the whole of the chin 
and halfway up the sides of the face and the upper half of the 
neck were shining, deep red, and swollen, with irregularly 
lumpy, flattish masses, from half a walnut in size downwards, 
brawny to the touch for the most part, but with here and there 
soft patches, some of which had already discharged. The whole 
affected area was covered with hair-pierced pustules, except 
where frequent bathing with hot water had caused them to 
rupture, and there were outlying discrete pustules beyond the 
confluent area. The hair had been allowed to grow for about 
a quarter of an inch, and was easily, and almost painlessly, ex- 
tracted even with the fingers, a characteristic early feature of 
the disease. Evidence of damaged nutrition of the hairs was 
not present. The dry, brittle, lusterless, broken or frayed 
stumps are, in my experience, found chiefly in cases of long 
standing. The chief sensation complained of was burning and 
tension, with only moderate tenderness. Between this and the 
first form described are all grades of severity and extent. 

The more severe forms may form convex elevations covered 
with pustular points exactly like kerion of the scalp. 

The disease is more acute in development than coccogenic 
sycosis, but unless properly treated is almost as indefinite in 
its duration, and even when apparently cured, will relapse if not 
carefully watched for some time, owing to some of the spores 
having escaped destruction. The suppuration also may be 
severe enough to destroy the follicles and produce cicatricial 
baldness of the part. This suppuration may be, and at the 
commencement generally is, solely due to the pyogenic char- 
acter of the fungus itself, but sooner or later pus cocci invasion 
occurs, and the features of coccogenic sycosis are mingled with 



TINEA BARBAE. 



*3 l 7 



the hyphogenic, and sometimes remain after the fungi are de- 
stroyed and thus prolong the disease. The disease may be as- 
sociated with or originate from ringworm elsewhere. Thus, in 
one of my cases, it appeared to have arisen from an eczema 
marginatum of the fork, this being followed by rings on the 




Fig. 95. — A hair from the beard in a case of tinea barbae. X 700 (Kaposi). 
a, the portion with ectothrix fungus; b, the part free from fungus. 

face. In another the patient was in the habit of rubbing his 
chin where the eruption was, with the back of his hand, and on 
this three rings of minute hair-pierced pustules appeared. 
Buzzi records the converse of this, in which a man with tinea 
sycosis gave a typical tinea circinata to his wife, and she to 
their child. 

Etiology. — The disease is generally contracted by those who 
are shaved by a barber, the fungous elements being probably 
conveyed by the shaving brush, and not by the razor, as is 



i 3 1 8 DISEASES OF THE SKIN. 

popularly believed. Of course it may also be derived from 
children or animals who are suffering from ringworm; but this 
is a less common mode. It is more common in young adults 
than in the elderly, but is independent of the general health, 
though doubtless some local predisposition, probably the softer 
texture of the hair of the chin, is an important factor. 

Pathology. — The disease is a folliculitis, usually pustular, of 
the hairy parts of the face, closely resembling coccogenic 
sycosis, but due to irritation from the presence of a fungus in 
the follicle. The severity of the inflammation, as compared to 
that of most cases of ringworm, is due to the pyogenic char- 
acter of the fungus. 

For the mode in which the fungus gains entrance into the 
hair, see the pathology of Tinea Tonsurans. 

The reason that the hairs are loosened in this form and not, 
as a rule, in coccogenic sycosis, is, as Robinson showed, that 
in the tinea form, the process begins inside the follicle and 
separates the follicular walls from the shaft, the inflammation 
spreading thence outwards, while in ordinary sycosis it begins 
without the follicle and spreads into it. 

The readiness with which the trichophyton attacks the beard 
is a proof that it is not the age of a patient, but an anatomical 
change in the hair substance, which prevents ringworm show- 
ing itself in the scalp in adults, in the same way as in chil- 
dren. 

Sabouraud's researches show that the fungus of suppurating 
tinea sycosis is always trichophyton megalosporon ectothrix, 
and of animal origin. 

He has described four clinical types, all ectothrixes, but from 
different animals and with different cultures. 

i. The typical kerion type due to the megalosporon of the 
horse. Culture of white colonies. 

2. Superficial moist inflammation in scattered patches of 
bovine or equine origin. Culture, yellow cribriform or vermicu- 
lar colonies. 

3. The diseased hairs are scattered and have an epithelial 
sheath over them, probably of avian origin. Culture, pale rose 
colonies. 

4. Like common endothrix of childhood, but of animal origin. 
Cultures, deep purple. 



TINEA BARBM. I3I9 

Three and four are rare in Paris, but Pelagatti finds it to be 
fairly common in Parma. 

5. Bodin adds an endothrix of human origin of which he has 
had five cases. Cultures, typical crateriform. Lesion was quite 
superficial in two-zoned, scaly patches, the outer pink and 
slightly raised. The hair breaks off short, is somewhat thick- 
ened, and the hair shaft filled with chains of spores. 

Ullman found that histologically in the kerion form there 
was first perifolliculitis with mononuclear leukocytes, then poly- 
nuclear leukocytes appear, which penetrate the root sheaths, 
distend the cavity of the follicle, and destroy its walls and the 
sebaceous glands. Giant cells were present. He thinks that 
the inflammation is excited by toxins. 

Diagnosis. — A rapidly spreading folliculitis of the face, accom- 
panied by brawny swelling, irregular lumpiness, loosening of the 
hairs, and perhaps evidence of their damaged nutrition, should 
lead to examination of the hairs by the microscope, when the 
fungus, if searched for carefully, will be found, but not in every 
hair from the diseased area. Those to which some root sheath 
is still attached are the most likely to show the fungus. Pro- 
longed soaking in liquor potassse is usually required, and 
in some cases repeated examination before it can be discov- 
ered. 

From coccogenic sycosis it differs in its more rapid spreading, 
the frequency of multiple foci of disease, the greater lumpiness 
and brawny swelling, and the early loosening of the hairs, which 
are for the most part extracted without pain or difficulty, and 
are often without their root sheath. 

From eczcmatous folliculitis, which may be even more acute 
than the tinea, it differs, in that an eczema is less scattered, is 
more superficial, unless of long standing, discharges serum at 
first; and even vesicles between the hairs may sometimes be 
seen. The eruption also is generally to be found in parts where 
there are no hairs, or at least a history of its having been else- 
where is generally obtainable, the free surface eczema often 
clearing up and leaving the folliculitis behind. There is an 
absence of brawny swelling and lumpiness, and the hairs can 
only be extracted with pain and comparative difficulty, and with 
their root sheath attached. 

Prognosis. — The disease may last for years if the cause is 



I 3 20 



DISEASES OF THE SKIN. 



unrecognized, but is always amenable to appropriate treatment 
perseveringly employed. 

Treatment. — The first and essential part of the treatment is 
systematic and complete epilation of the affected area. Each 
day a square inch or so should be cleared of hairs — and, owing 
to the loosening of the hairs, this is easily effected — and the 
parasiticide applied immediately afterwards. I do not agree 
with Jamieson that the acuteness of the inflammation is a con- 
tra-indication for the immediate employment of parasiticides; 
on the contrary, that inflammation speedily subsides when its 
cause is destroyed. 

The strength of the parasiticide need not be so great as that 
for ordinary tinea tonsurans. The formulae suitable for kerion 
are suitable here also, such as oleate of copper oss to 5J 5 
sulphur oj, acid, carbolic, oss, lanolin c. oleo §j; and others 
are described in the treatment of acutely inflammatory 
tinea tonsurans. In this way the great bulk of the dis- 
ease is speedily removed, but watchful care and persever- 
ance are often required for some time, in order to insure 
complete stamping out of the vitality of the last spore of the 
fungus. The abscess-like swellings do not require incision, as 
the removal of the hair is sufficient to allow the pus to escape. 
Poultices should never be employed, as they favor the spread 
of the fungus. The milder forms require the same treatment as 
for tinea circinata, combined with epilation. It has been stated 
that iodid of potassium internally has a curative action. 

Tinea ciliorum, ringworm of the eyelashes, is a very rare 
affection, only four cases being on record, though probably it 
often escapes recognition. In one of Mibelli's cases,* a child 
of six, it was contracted from a cow; the father also had it in 
the beard. Mibelli found that in the eyelashes the fungus was 
distinctly endothrix, while in the father's beard it was ectothrix, 
and as both came from the cow, he argues that it is the nature 
of the soil which determines whether the fungus is inside or 
outside the hair; moreover, it would upset Sabouraud's theory 
that all endothrix is of human origin. 

* " Blepharitis Trichophytica," Mibelli, Giorn. Ital. delle mat. vener. e 
delta pelle, Fasc. III., 1894, and Monatshefte f. prakt. Der??i., vol. xix. 
(1894); abs. Brit. Jour. Derm., vol. vii. (1895), p. 64. 



ONYCHOMYCOSIS. 132 1 

The cilia were broken off short, generally concealed by a 
scale, and there was marked redness and swelling of the lid. In 
another case, an adult, the cilia were distorted, many broken, 
and pus round some others, In both cases there was tinea 
circinata on other parts of the face, which was the key to the 
diagnosis. 

The successful treatment was epilation and the application 
of a 1 in 5000 perchlorid of mercury, 

ONYCHOMYCOSIS.* 

Synonyms. — Tinea' unguium. 

Strictly speaking, this term applies to favus as well as to ring- 
worm of the nail, but the former is very rare and has been 
described under favus, and only ringworm of the nail has now 
to be considered. According to Sabouraud, tinea unguium is 




Fig. 96. —Trichophyton endothrix of nails. Zeiss D. D. 10 in tube. 

always due to the trichophyton megalosporon ectothrix fungus, 

but Pernet has found endothrix in one of my cases, and in two 

(sisters) in his own practice. The appearances are very varia- 

* Author's Atlas, Plate XC, Fig. 12. 



1322 



DISEASES OF THE SKIN. 



ble. Dubreuilh * says that invasion is usually by the side of the 
nail or by the subungual epidermic involution, seldom at the 
free border, and that it is always secondary to an old tinea 
circinata. It would also occur in childhood from scratching the 
head if affected with ringworm, and then would enter by the 
free border. Dubreuilh himself records such a case, a girl with 
kerion of the head and tinea unguium. It leads to a dirty yel- 




Fig- 97. — Onychomycosis from tinea tropica, affecting toe nails. The 
disease had been present ten years, and the nails were chipped and 
crumbled. It was called in India " dhobie itch," and was supposed 
to have been cured by gunpowder. Zeiss D. D. 10 in tube. 

lowish or blackish discoloration of the nail with thickening, due 
to partial separation of the component layers, chipping and 
splitting of the free border, dullness or roughness, or a fibrous 
surface, the surface layers being sometimes exfoliated. Ex- 
treme onychomycosis is sometimes seen on the toes, or there 
may be only opacity and loss of polish. 

There may be transverse ridging or longitudinal striation; 

*Arnozan and Dubreuilh, Archives Cliniques de Bordeaux, February, 



TINEA IMBRICATA. 



1323 



separation from the nail bed sometimes occurs. There is thus 
nothing distinctive from other trophic changes except asym- 
metry and chronicity, and unless there is a history of a more 
characteristic lesion, on the hands or elsewhere, the nature of 
the affection would probably not be suspected. Ehlers has 
found it very common in wool carders in Iceland. The disease 
may last for any number of years. 

In one of my cases, a man over sixty came to the hospital 
with tinea circinata affecting tjie back of the hand, subse- 
quently two nails, the second and third, became affected, and 
scrapings showed the same fungus (megalosporon endothrix, 
Fig. 96). The index finger nail being noticed to be something 
like the others, he' said it had been so from boyhood, and 
scrapings showed fungus in it also. (Fig. 1, Plate IV., shows 
a hair from his first phalanx.) In another case a lady con- 
tracted tinea of the sole of the foot ten years previously in 
India, her toe nails had been affected ever since (Fig. 97). 

In order to find the fungus very prolonged soaking (twenty- 
four hours sometimes) of scrapings in liquor potassse is neces- 
sary, and it is better to use a forty per cent, solution. The 
complete disintegration of the nail substance thus produced is 
advantageous for finding the fungus. If there is any lesion on 
the back of the hand the hairs on the proximal phalanges 
should be examined. 

TINEA IMBRICATA.* 

Synonyms. — Tokelau or Bowditch Island ringworm (lafa Toke- 
lau); Le Pita; Gune; Cascadoe; Herpes desquamans. 

Definition. — A tropical, vegetable parasitic, contagious dis- 
ease, characterized by the formation of patches of concentric 
scaly rings. 

It is usually said that the first medical description of this 
disease was in 1844 bv Fox in America, under the name of 
" gune " (native word for skin), but Alibert gives a plate of it 
from a child from Port Dorey in his quarto of 1832, p. 492. 

* Literature. — Hirsch's "Geographical and Historical Pathology," 
vol. ii. p. 375. "Med. Rep. of Imp. Maritime Customs for China," 1879; 
abs. in Med. Times and Gazette, vol. ii. (1879), P- 34 2 - McCall Anderson, 



i3 2 4 



DISEASES OF THE SKIN. 



Subsequently it was reciescribed by Turner, Koniger for Samoa, 
Manson for the Malaccas and China, and Macgregor for Fiji. 
It is confined to the tropics; and although spread pretty widely 
over the various groups of islands in the South Pacific, it has 
been especially prevalent in the Malay Archipelago and the 
Gilbert Islands, where Fox observed it, and whence it spread 
to the Tokelau and Samoan groups. It has also been observed 
in Burma and Southern China. It is most prevalent in a damp 
equable climate with a temperature between 86° F. and 90 F. 
and extremes of temperature prevent its extension. The cas- 
cadoe of the Malaccas, described by P. van Meederwoort, is evi- 
dently the same disease. It has never been seen in England. 

Symptoms. — With rare exceptions the disease avoids the 
scalp, face, and forehead; and even when it invades other hairy 
regions, the fungus, Manson says, does not invade the follicles, 
leaving, consequently, the hair unaffected; but Koniger * states 
that the hair on the body (not the scalp) is almost destroyed 
where the eruption has occurred. Tribondeau says the nails 
are always spared. 

With the exception of the head, it may attack any part of the 
body; and when it has existed sufficiently long unchecked, it 
may spread over a whole limb or region, or the entire body 
surface. 

A separate, fully developed patch consists of concentric rings 
of scales, these rings being about a quarter of an inch apart, 
and eventually filling up the whole patch, which then looks like 
watered silk. The scales vary in size up to half an inch square, 
and are free at their external edges, which are slightly curled, 
except in old cases, when they become large, thick, and horny, 
and give the body the aspect of being coated with clay; hence 
the native name, meaning " clay-skin." " The appearance of 
comparatively recent patches," Turner says, " may be imitated 
by taking a sheet of stout cardboard and shaving the upper 
layer of it in such a way as to make it curl up in circles." 

Ed. Med. Jour., for September, 1880, with plates. Manson, Brit. Jour. 
Derm., vol. iv. (1892), p. 5, with history and bibliography. Nieuwenhuis 
(Java), "Tinea Imbricata," Archiv f. Derm. u. Syph.,vo\. xlvi. (t8q8), 
p. 163, with plate of cultivations. Tribondeau, Arch, de Med. Navale 
et Coloniale, July, 1899, p. 5; full abs. Brit. Jour. Derm., vol. xi. (1899), 
p. 400, and note by Manson. 

* Virchow's Archiv, 1878, Bd. 72, p. 413- 



TINEA IMBR1CATA. 



3 2 5 



Koniger describes the disease as beginning " with an eruption 
of small papules, mostly grouped in circles, which cause intense 
itching and desquamation round their growing periphery. 
Afterwards these circular efflorescences coalesce, the skin be- 
coming at the same time hard, dry, and brittle." Tribondeau 
says that the initial lesion may also be vesicular, with clear or 
slightly yellow fluid; that rings develop from them more rapidly 
than from the papules, which he describes as rounded, hard, 
grayish-yellow with a pale pink border. Patrick Manson has 
repeatedly inoculated the disease, and thus describes its devel- 
opment: "After inoculation there is an incubation period of 
about nine days. At the end of this time the fungus has multi- 
plied sufficiently to slightly elevate the epidermis under which 
it is growing, and form a brown mass between it and the 
corium. When this has reached a diameter of about three- 
eighths of an inch, the epidermis in the center gives way; but 
as it is still organically continuous with the sound skin at its 
margin, it is not completely shed, but remains as a fringe round 
the central depression. By friction or other means the free 
edge of the scale is from time to time removed, and the brown 
central fungus and the tissue it is mixed with, now no longer 
protected by a closely adhering epidermis, are rubbed off as 
far as the attachment of the scale, and the exposed corium 
appears pale. Just beyond this point' the advancing fungus 
shows through the epidermis as a brown rim, perhaps very 
slightly elevated, about one-sixteenth of an inch in breadth. 
When the entire ring thus formed has attained a diameter of 
about half an inch, a brown patch is again seen to be forming at 
its center; this, in its turn, also cracks the young epidermis over 
it, and a second ring is formed inside the first, which it follows 
in its extension. A third brown central patch is formed in the 
center of the second circle, and behaves in exactly the same 
manner, and so on with a fourth, fifth, and a never-ending 
series of concentric rings," but Tribondeau never saw more 
than four. 

The patches extend at the rate of a quarter to half an inch 
a week. 

The only symptom attending the eruption is the intense itch- 
ing, and the consequent scratching is an important factor in 
spreading the disease. Where the scales have come off stains 



1326 DISEASES OF THE SKIN. 

are left in rings, or sinuous lines of a livid color remain, which 
are very persistent, and may be permanent. The disease is 
much dreaded by the natives, but, though very disfiguring, is 
not injurious to the general health. 

Etiology. — The disease is undoubtedly contagious, attacks 
both sexes at all ages, but especially children, Meederwoort stat- 
ing that it always begins from the second to the fourth year, 
but this is only true for a large proportion. It is tropically 
endemic. Manson thinks it requires special climatic peculiari- 
ties for its development. 

Pathology. — Koniger and Manson were the first to demon- 
strate its fungous parasitic origin, and Manson called the dis- 
ease and fungus, tinea imbricata. The fungous elements are 
confined to the epidermic layers, especially the under surface, 
and do not affect the hair follicles; and according to McCall 
Anderson (with whose observations those of Manson, made on 
fresh scales, nearly agree), who examined some of the scales, 
as compared to tinea circinata the fungus is much more 
abundant, the chains of spores much more numerous than the 
mycelial threads, and the spores, though of the same size, in- 
stead of being round, are oval, rectangular, or irregular, while 
the mycelial threads are long, straight, or gently curved; but 
Siegfried, on the other hand, writing from Amoy, says that 
the mycelium is large-sized and predominates over the spores, 
which are sparse. Tribondeau also found abundant mycelium. 
Nieuwenhuis of Java succeeded in cultivating the fungus on two 
per cent, agar and five per cent, malt extract and other media, 
with a slight alkaline reaction. The development was very 
slow. He and Sabouraud regard the fungus as a large-spored 
trichophyton, very like European animal trichophytons. Per- 
net, from material sent him from Pahang, describes the fungus 
as consisting of masses of interlacing mycelium, some plain, but 
most with short, thick, round segments, and dichotomous 
branching. The spores were numerous, scattered about in rows 
and clumps. 

Diagnosis. — This would offer no difficulty in the regions where 
it is endemic. The concentric scaly rings which tend to fill up 
the central area, while the outer ring is spreading peripherally, 
differ completely from tinea •circinata, in which the central area 
clears pari passu with peripheral extension, except in a few cases 



TINEA VERSICOLOR. 1327 

which were described under Tinea Circinata, but even then 
there would not be the flaky scaliness and the pigmentation. 

Treatment. — Although the fungus is quite superficial, this is 
more difficult than might be expected. The clothes and other 
coverings should be destroyed or disinfected. The scales should 
be removed by alkalin or sulphid of potassium baths, and then 
Manson recommends linimentum iodi, double strength, painted 
on to a limb or other portion of the body, and extended each 
day. Other methods of treatment would be the same as for 
the more obstinate forms of tinea circinata. Goa powder or 
chrysarobin, applied as there directed, is one of the most 
efficacious means of cure. It is best applied after a hot soft 
soap bath followed by pumice-stoning. Relapses, especially 
when the dirty belongings are retained, must be watched for 
and promptly dealt with. 

TINEA VERSICOLOR. 

Synonyms. — Pityriasis versicolor; Chloasma (old name); My- 
cosis; microsporina; Ger., Kleienflechte. 

Definition. — A vegetable parasitic disease, situated chiefly on 
the trunk, which is characterized by patches of various sizes, 
shapes, and shades of brown color. 

This disease is more common than might be inferred from 
dermatological statistics, which in England and America give 
rather more than 1 per cent., Huble, in France, having found it 
in 68 per cent, in examining over two thousand healthy young 
soldiers; in my own clinic it is less than 1-2 per cent., while in 
Duhring's it is over 2 1-2 per cent., and in the hot countries of 
the East it is very common. 

Symptoms. — Practically it may be said to be confined to the 
trunk, though in a few cases it extends a little beyond, to the 
neck, thighs, and arms, and even to other parts. 

It occurs either in discrete, roundish spots or patches, of the 
size of a split pea and upwards, which may remain separate and 
be scattered freely over the body, but more frequently they 
coalesce into large, irregularly outlined tracts, which may cover 
the whole trunk, but generally more on the front than the back. 
Discrete patches, in greater or less numbers, are usually scat- 



1328 DISEASES OF THE SKIN. 

tered beyond and between the main tracts; the extent, how- 
ever, is very various, and there are all gradations, from one or 
two moderate-sized patches upwards, but the bulk of the disease 
is generally on the chest, abdomen, and interscapular region. 

The patches are usually of a fawn color or some other shade 
of brown. The edges are sharply defined, especially where they 
are extending, but scarcely perceptibly raised above the sur- 
face, which is usually slightly furfuraceous, unless sweating is 
profuse, when it may be smooth and greasy to the touch. On 
scratching it with the nail much of the discoloration can be 
removed, either in scales or rolls, for the growth affects chiefly 
the superficial epidermic layers. Itching may or may not be 
present, but it is seldom very marked. The patches spread 
slowly, as a rule, but may extend rapidly in a very congenial 
soil. If untreated, it may last indefinitely, and it has a great 
tendency to relapse after apparent cure. 

Variations. — In a few cases the disease extends for some dis- 
tance down the limbs ; I have seen it in the popliteal space three 
times and on the elbows twice; and Dubois-Havenith observed 
it covering almost the whole of the arm and forearm to the 
wrists, and over the neck. It may even affect the face, though 
it is rare for it to extend beyond the covered parts. Thus 
Biart * of Nebraska records a case of a man in whom there 
were pea- to finger-nail-sized patches on the left cheek up to 
the external canthus, and a continuous band over the greater 
part of the forehead, which encroached slightly on the scalp; 
there was also a spot behind the ear, while on the trunk it was 
very extensive, and reached down both arms, on the right ex- 
tending to a little below the elbow. Payne also found the 
microsporon furfur abundantly in the scales from the scalp and 
beard, where apparently there was only a simple pityriasis, but 
the patient had had tinea versicolor on the trunk for some years. 
In Assam A. Powell f says that it is very common on the face ; 
he ascribes this to the fact of the natives rarely using soap. 

Gottheil J relates the case of a Cuban medical man, who had 
black spots on his left palm for fifteen years. The lesions con- 

* Amer. Jour. Cut. and Ven. Dt's., vol. iii. (1885), p. 73. 
f Lancet, December 30, 1899, p. 1809. 

%New York Med. Rec. July 1, 1899, p. 15. Abs. in Brit. Jour. Derm., 
vol. xi. (1899), p. 403). 



TINEA VERSICOLOR. 1329 

sisted of discrete round macules in places running into slightly 
scaly patches of a dark brownish-black color. Microsporon 
furfur was diagnosed from microscopical examination. A. Coffin 
met with the case of a woman who contracted it from her hus- 
band seven months after marriage, and the patches almost dis- 
appeared at each monthly period. 

Sometimes, chiefly in persons who sweat profusely, the dis- 
ease commences with, or is accompanied or followed by, signs 
of inflammation. The patches are then red and often very 
itchy, and occasionally may become eczematous. The color 
also may be much darker than usual; I have once seen it dark 
brown; and even black (pityriasis nigra) is recorded by Willan, 
Cazenave, Tilbury Fox, Gottheil, and by C. W. Allen on the 
neck. These black cases were in individuals who had been in 
hot climates. According to Hebra, however, the pityriasis 
nigra of Willan is really the pigmentation which follows pro- 
longed phthiriasis. On the other hand, Lutz, writing from 
Honolulu, points out that in colored races it produces white, or, 
where the fungus is very abundant, gray discoloration of the 
skin. The whiteness persists for some time after the fungus 
has been destroyed, and he attributes it to the layer of fungus 
preventing the light from exerting its usual actinic effect, and 
so the dark color is not developed in the material from which 
the pigment is formed, and this can be recognized in the rete, 
but without coloration. 

Etiology. — Eichstedt of Greifswald, in 1846, was the first to 
demonstrate that the disease was due to the growth of a fungus 
which he called microsporon furfur. It is contagious, but only 
to a slight degree, requiring a congenial soil, not to be found 
in all persons, and prolonged contact, as in the occupants of 
the same bed, though husband and wife do not necessarily com- 
municate it to each other. Kobner succeeded in inoculating 
"both men and rabbits with the fungus. It affects both sexes, 
but men rather more frequently than women in my experience, 
but it is seldom seen in the very young or very old, occurring 
chiefly between twenty and forty. The extremes, in my experi- 
ence, are sixteen and seventy years, but Sidney Phillips showed 
a case at one of the Societies of a boy, set. seven and three- 
quarters, with patches on the chest and back. It is certainly 
more common in those who perspire freely, and this may ac- 
84 



133° 



DISEASES OF THE SKIN. 



count for its being seen so often in the phthisical, though some 
think that malnutrition is the favoring factor. It is certain, 
however, that it is by no means infrequent in perfectly robust 
individuals, and cleanliness is no safeguard' against it, though 
it would be less likely to attack, and spread much less slowly 
in, people who wash thoroughly and frequently change their 
underclothes. According to some experiments of Daguet and 
Hericourt,* however, the fault is on the other side, and they 
think that the microsporon furfur fungus produces phthisis, in 
some instances, as they found this fungus in the diseased tissues, 
and the injection of the fungus rendered guinea-pigs and rabbits 
tubercular. These deductions are a priori improbable, and the 
experiments require confirmation before they can be accepted 
as correct. Two other French observers assert that it only 
occurs in persons who have both seborrhea and dyspepsia. 

Pathology. — The color is mainly due to masses of strongly 
refracting conidia, which are situated almost entirely in the 
upper part of the horny layer, and Waelsch says they never 
go below that layer. According to Gudden they also penetrate 
into the lanugo hair follicles. The microsporon furfur is one 
of the most characteristic fungi of the skin. The conidia are 
arranged in closely crowded conical heaps, around which are 
the mycelia, interlaced more or less together, and connecting 
the neighboring heaps of conidia. The conidia are, as a rule, 
round, larger than those of ringworm, rather smaller than a 
red-blood corpuscle, and fairly uniform in size. They consist 
of transparent protoplasm, inclosed in a doubly contoured mem- 
brane, containing a strongly refracting yellowish nucleus. The 
mycelia are not very long, for the most part unbranched, and 
may be even or jointed, singly or doubly contoured with 
nuclei at regular intervals, and, when fully developed, show 
conidia at their termination, these latter coming off either di- 
rectly from the mycelia or budding from each other (Fig. 98). 

The fungus can be readily detected by washing the scrapings 
in ether to remove the fat and then examining them in liquor 
potassse, taking care to tease out the masses, so as to get a 
sufficiently thin layer. 

Spietschka f found that, while cultures in the same media 

* Abs. of their paper in Lancet, May 8, 1887, " Pityriasis and Phthisis.'* 
f Archiv f. Derm. u. Syph., vol. xxxvii. (1896), with plate 



TINEA VERSICOLOR. 



133 



were identical in twelve cases, when the medium was varied 
very different-looking cultures resulted. He reproduced the 
disease from pure cultures. 

Matzenauer * also cultivated the fungus; he started on Fin- 
ger's " epiderminagar," and was then able to transplant it on 
to the ordinary media, and grew yellow or amber colonies on 
agar and liquefied gelatin. The older the colony the greater 
the spore development. Gastou and Nicolau f confirmed Matze- 
nauer's observations, but made their cultivations on gelose 




Fig. 98. — Microsporon furfur from a woman, set. 70. X Zeiss D.D. 10 in. 

tube. 



moistened with placental serum, but with many failures. The 
only mode of development they observed was endo-sporulation. 
Diagnosis. — The yellowish-brown discoloration situated chiefly 
on the trunk, and capable of being peeled off by scraping with 
the nail or a knife, and the microscopical appearances are dis- 
tinctive. The diseases most like it are seborrhoca papulosa, or 
lichen circinatus; pityriasis rosea; and erythrasma. The differ- 
ences from the last are given under that disease. 

* Loc. cz't., vol. lvi. (1901), p. 163. 
f Annates, vol. iii. (1902), p. 414. 



1332 DISEASES OF THE SKIN. 

Seborrhea papulosa does not travel beyond the trunk, has a 
red, papular margin, and is more often in separate small 
patches than tinea versicolor. The microscope would always be 
decisive in a case of doubt. 

Pityriasis rosea is acute in course, affects the limbs as much 
as the trunk, has fine, silvery scales, and only faint discolora- 
tion when it is fading and the inflammatory symptoms have 
subsided. 

Prognosis. — The disease is always amenable to treatment. 

Treatment. — The skin should be thoroughly washed with 
plenty of soap and warm water — soft or pumice-stone soap 
preferably if the skin is not very delicate — and scrubbed with 
a nail brush; the greasiness of the skin is thus removed, and 
the superficial layers roughed up, which allows the parasiticide 
to penetrate more thoroughly. The skin is then rubbed with 
a piece of flannel dipped in the following lotions: sodae hypo- 
sulphitis Jss, aquae destillat. 5 vn J' immediately followed by tar- 
taric acid 3ij, aquae o vn J> by which nascent sulphur and sulphur- 
ous acid are produced in the skin. 

The under-flannels must be thoroughly baked, boiled, or 
preferably thrown away. This treatment should be repeated 
once or twice a day, and never fails to cure, provided that the 
patient, even after the disease is apparently well, watches for 
some months for any reappearance, and attacks the smallest 
recurrence immediately. Disappointment frequently follows 
from the neglect of this precaution. A few spores here and 
there, lying perhaps deeper than the rest, escape destruction 
at first, and, when left unmolested, are the new starting-point 
for fresh patches. The above treatment is the one I invariably 
adopt, as it is effectual and convenient, but there are many other 
methods. Any of the parasiticides recommended for tinea 
circinata will do; preparations of thymol, chrysarobin, sulphur, 
fresh sulphorous acid (formulae for which may be found at the 
end), are all effectual. 

They all, however, require the same watchfulness against re- 
currence; and watery lotions must be preceded by soap-and- 
water ablution to remove the grease. Vigier recommends 
merely mechanical treatment, viz., prolonged frictions with 
finely powdered pumice stone fifty parts, soft soap one hun- 
dred parts; or Unna's marble soap would act in the same way; 



ERYTHRASMA. 1333 

but hyposulphite of soda or sulphurous acid lotion used after 
the soap would render the cure more rapid. 



ERYTHRASMA.* 

Definition. — A vegetable parasitic disease producing brownish 
patches. 

This trivial affection was first described by Burchardt (1859), 
and then by Barensprung (1862), and later by Besnier, Balzer, 
Dubreuilh, Riehl, Weyl, Kobner, Payne, etc., who all regard 
it as a separate affection, with which I agree. It is not very 
uncommon in men, but more so in women, and as it produces 
no inconvenience, is usually only discovered accidentally. 

Symptoms. — It occurs almost exclusively in the folds of the 
axillae, inguinal and genito-crural regions, the cleft of the 
nates, and the adjoining parts of the trunk or limbs, usually by 
extension, but sometimes arising there independently. Reale 
also observed it in the bend of the elbow, and cultivated the 
organism. It occurs as roundish or irregular outlined, well- 
defined, slightly furfuraceous patches, of variable size at first, 
of a uniform reddish; later on, of a yellowish, reddish, or dark 
brown tint, and slightly unctuous to the touch. The patches 
are generally few and small, but occasionally it covers a large 
area, as in Besnier's case, where it extended all over the thighs 
and upper arms, but as a rule it is confined to warm and moist 
situations. It spreads very slowly; if not treated, it may re- 
main for years unaltered, producing no symptoms, or only very 
slight itching. Riehl's youngest case was sixteen years, his 
oldest fifty-eight. A case of mine was sixty-six. 

Pathology. — Many writers have regarded it as a tinea ver- 

* Literature. — Burchardt, "Ueber eine bei Chloasma vorkommende 
Pilzform." Med. Zeitung, T859, P- T 4 T - Barensprung, Ann. des Charite 
Krankenh., 1862, Bd. x. Balzer, Ann. de Derm et de Syph., vol. iv. 
(1883), p. 681, and vol. v. (1884), p. 598. The first contains a plate of the 
parasitic elements, the second a good general account, with bibliography. 
Ziemssen's '* Handbook," p. 526. There is a good abstract of Riehl's 
paper in Amer. Jour, of Cut. and Ven. Dis., vol. ii. (1883), p. 84, with 
woodcuts. Payne, Path. Trans., vol. xxxvii. (1886), p. 516. Ducrey and 
Reale, " Contribuzione alio studio dell' Erythrasma." Naples, Angelis- 
Bellisaris (1893), and Monatshefte f. p. Derm., vol. xix. (1894), p. 414. 



i 3 34 DISEASES OF THE SKIN. 

sicolor or an eczema marginatum, but all the authorities above 
mentioned are agreed that it is due to a separate vegetable 
parasite, which Barensprung called microsporon minutissimum. 
A power of five or six hundred diameters is required to see the 
organism well. Payne regards it as a " mucor in its mycelial 
stage without sporangia"; he describes it as consisting of a 
series of interlacing jointed threads, with segments of unequal 
length and variable thickness, sometimes terminating in 
slightly swollen, blind extremities, but without branching; they 
were situated between or at the borders of epithelial scales; he 
was doubtful whether there were any true spores. Balzer, on 
the other hand, describes, in addition, groups of minute spores 
here and there; in size, these various elements were about one- 
third those of tinea tonsurans. Neither Balzer nor Payne 
agrees that the spores, etc., found by Bizzozero in normal skin, 
especially between the toes, are of the same characters as micro- 
sporon minutissimum. 

Ducrey and Reale consider that it is a fungus cultivated with 
difficulty, and consisting of minute spores and fine mycelial 
threads, and that its presence in erythrasma is constant and 
abundant, and at the same time cultures from normal skin, and 
pityriasis versicolor, show the same fungus, but in small quan- 
tity. Inoculation experiments with erythrasma cultures or 
scales have hitherto been unsuccessful; still, they think it is the 
real cause of the disease, but that it requires a special soil, a 
suitable condition of moisture, and of decomposition of secre- 
tions for its full development. They say that the parasite easily 
cultivated by Pasquale de Michele * was a schizomyces but do 
not explain his claim to have reproduced the disease in the 
inguino-scrotal region from cultivations. He also found the 
common leptothrix epidermidis in the scales, but inoculation of 
cultures produced no result. 

Diagnosis. — The only disease for which it could fairly be mis- 
taken is tinea versicolor. The absence of the disease to any 
extent on the trunk, the slighter disturbance of the horny 
layers, and the darker or redder color of the patches ought to 
suggest its nature, but in doubtful cases microscopic examina- 
tion would be required, when the different characters of the 

* Giornale Internaz. de Scien. Med., November 15, 1890. Abs. Brit. 
Med. Jour., April 18, 1891. 



PINTA. 1335 

parasite of the two affections would be obvious ; in the absence 
of the well-marked signs of inflammation of tinea cruris one 
would distinguish it at once from that disease. 

Treatment. — This is the same as for tinea versicolor, and the 
same precautions against recrudescence are required. 

PINTA.* 

Synonyms. — Spotted sickness; Mai de los pintos; Mai del 
pinto; Tina (Mexico); Caraate, or cute, i. e., look at his 
face (Venezuela and Granada); Quirica (Panama); Pannus 
carateus (Alibert). 

Definition. — A tropical, contagious hyphomycetic disease, 
which produces discoloration of the skin. 

The disease appears to be confined to the tropical regions of 
America between 27 north and 28 south, especially along the 
river banks. Possibly some of the discolorations in other parts 
of the world, such as the lola of Surinam, may be of a similar 
nature and Legrain has reported an achromia (not leukodermia) 
from the Sahara and a colored skin disease which occurs in 
groups in Tripoli which he identifies as pinta, but he could not 
discover the fungus. True pinta occurs extensively on the west 
coast of southern, and in other parts of Mexico; in Colombia, 
New Granada, Brazil, especially in the province of San Paolo, 
and sparsely in Panama, Peru, and Chili. It is said to have 
been imported into Mexico in 1775 from South America, where 
it was prevalent before the Spanish conquest of Mexico; but 
this can scarcely be correct, as it mentioned in the Encyclo- 
pedia of Polanko of Mexico in 1760, and was the subject of 
Aztec prayers for centuries. It was described by Alibert in 
his 1832 edition. 

Symptoms. — Following Iryz of Mexico: the disease consists 
-of scaly spots, very variable in color, shape, number, and size, 

* Literature. — Hirsch's "Geographical Pathology," vol. ii. p. 379; a 
full account with bibliography to date, Brit. Med. Jour., vol. ii. (1882), 
p. Q03; abs. from paper by Dr. Iryz read before Academy of Medicine in 
Mexico. E. Lier, Letter from Mexico to Monatsh. f. ftrakt. Derm , vol. 
xiv. (1892), p. 447, with history and some Mexican bibliography. A. Gavino, 
Mexico, Inter. Cong., Rome, 1894, Trans., p. 33. 



1336 DISEASES OF THE SKIN. 

and appears to be allied in its characters to tinea versicolor. 
It usually begins on uncovered parts, such as the face and ex- 
tremities, but may affect the scalp and all parts of the body 
except the palms and soles. It varies in extent from quite a 
small area to almost the whole body surface. New patches may 
be continually forming. While they increase in size, both by 
peripheral extension and by confluence with their neighbors, 
they are not at all, or very slightly, raised above the surface. 
Their shape may be roundish or irregular, sharply defined or 
shading off into the healthy skin, of black, grayish, blue, red, 
or dull white hue. The first three are superficial and spread 
rapidly; the red and white affect the rete mucosum and corium 
and spread slowly. There are thus two classes: the epidermic 
and subepidermic. Sometimes all these colors are present on 
the same individual, though at first all the spots were of one 
color, and only at a later stage were the new spots of different 
tint; or the patches may be of uniform tint throughout the 
whole course of the disease, and the individual patches never 
change color after they have come out. The patch is furfurace- 
ous at first, chiefly in the black and blue forms, but the scales 
are larger in advanced cases, and the surface usually feels 
rough and dry, seldom moist and greasy or glutinous. In the 
red form ulceration sometimes occurs. The white form does 
not itch nor desquamate, and in many cases there is no fungus 
to be found. In hairy parts the hairs get thin, turn white, and 
ultimately fall out.* Some of the blue cases look as if tattooed 
with gunpowder, while the white patches have a cicatricial 
aspect, with a dark ring, and the skin is hard with diminished 
sensation- The itching is in proportion to the scaling, and may 
be very intense, and the patient's emanations are offensive, 
smelling, according to some, like foul or mildewed linen, or, 
as others say, like cat's urine. No other symptoms are present, 
except those due to scratching, though, according to some 
authors, severe gastric symptoms, which last from four days to 
a week, precede the outbreak in a few cases, the skin eruption 
not appearing until six weeks later: probably such symptoms 
have no relation to the disease. 

While the disease is always chronic, lasting months or years, 
or even all the patient's life if untreated, it often spreads but 
* Montoya y Florez says the scalp and beard are never attacked. 



PINTA. 



1337 



very slowly, or remains stationary for a long time in the red 
or white form, while in the black and blue variety the extension 
may be very rapid and general. 

According to Montoya y Florez, who has studied caraate in 
Colombia, the red variety attacks almost exclusively white peo- 
ple, and is not confined to the poor. Beginning on the back of 
the hands and feet, it then attacks the neck and face, at first as 
defined red scaly patches, then festooned or maplike, and finally 
extends over the whole body, which becomes of a brick-red 
color. Ulceration sometimes occurs, and on the palms, soles, 
and lips, painful fissures. It runs a slow course and may last 
indefinitely. It flourishes in towns and in the shade. The violet 
black form is chiefly seen in negroes, only three per cent, of the 
cases being whites. It is seen chiefly in outdoor workers, at- 
tacks first parts exposed to the sun or injuries, finally extends 
all over the body, but only after many years. It is a more super- 
ficial and milder form than the red variety. He also describes 
the violet, gray, and bluish-violet forms. The white form Mon- 
toya says is the final retrogressive stage of any variety except 
the red. In the black and blue cases the patch is furfuraceous 
at first.* 

Etiology. — It attacks both sexes and all ages, except infants 
in arms. The disease is contagious, and, as might be expected, 
it is most prevalent where there is dirt and neglect, and hence 
it is more common in the poor than in the rich, and among the 
dark races and half-castes than among the whites, though all are 
liable to it under circumstances favorable for its development. 
A tropical climate which includes moisture as well as warmth 
is evidently one essential factor, while an elevation above five 
thousand feet and a mean temperature below 6o° F. are un- 
favorable conditions. Though it may commence in sound skin, 
a dermatitis such as eczema favors its development. 

Pathology. — Gastambide has clearly shown the fungous origin 
of the pinta of Mexico, which Sabouraud says (without stating 
his reasons) is analogous, but not identical, with caraate of 
South America. 

* Barbe has described a case from Colombia which he observed in Paris, 
and traced stages of erythema, deeper red, going on to bluish tint, then 
hyperchromia, and finally achromia. The hairs on the achromic parts 
became white and did not fall out. 



1338 DISEASES OF THE SKIN. 

Anatomy. — Gastambide's fungus is situated in the epidermis, and his 
observations favor the view that the black and blue spots are more 
superficial, never going beyond the horny layers, and when the disease 
is cured leaving no trace behind; while in the red and white the deep 
parts of the rete are involved, and Iryz says the corium also, and per- 
manently white spots may mark the site of the previous eruption; and in 
one of Iryz's cases the whole body, including the hair, was left quite 
white. 

The fungous elements consist of roundish and oval spores about eight 
fi in diameter, and tapering in branched mycelial threads, to which the 
conidia are attached. The results of Montoya y Florez's studies of 
Colombian caraate as given by Sabouraud * are as follows : The caraates 
are the aspergilloses of the skin, and each form has a separate species 
(about twenty so far). The fungi appear as long dichotomous filaments, 
very fine, smooth, and cylindrical, sometimes granular and in chaplets. 
At some points a close reticulum is formed, from which emerge two, 
three, and four fine mycelial threads side by side; elsewhere by dichotomy 
a fine filament emerges, and a short thick branch, which generally ter- 
minates in a relatively voluminous fructification, characteristic of the 
particular species of caraate under observation. Not only the mycelium, 
but the fructification can be found in the epidermis under the microscope. 
He traces the fungi to a saprophytic origin, as he has found a violet ash- 
colored form in the water of gold mines, which contain sulphate of iron 
and copper, and various forms in certain species of mosquitoes and bugs. 
It has also been found on some cereals. The analogy of these observa- 
tions to those of Sabouraud on the trichophytons is obvious, as is also the 
inference that we are far from finality on the subject. At the same time 
they rendered obsolete the conclusions of Lier of Mexico, that it is merely 
a pigmentary non-contagious, but hereditary malady, unaffected by 
public hygiene, and only requiring treatment on esthetic grounds. 

Diagnosis. — The diagnosis can offer no difficulty in countries 
where it is endemic. 

The treatment is the same as for tinea versicolor, but, like it, 
the skin must be watched carefully for some time to eradicate 
any recrudescence from spores which have escaped destruction. 
Probably chrysarobin would be the most efficacious, but Mon- 
toya says that mercurials are certain cures, but it is obvious 
that they must not be used over a large area at once. Barbe 
found citrine ointment efficacious. 

* Annates de Derm, et de Syph., vol. ix. (1898), p. 673. 



ACTINOMYCOSIS OF THE SKIN. 1339 

ACTINOMYCOSIS OF THE SKIN.* 

(axriS 9 a ray; /avhtj?, a fungus.) 

Definition. — A parasitic affection due to the ray fungus, which 
excites suppurations and granulation, sarcoma-like tumors in 
the tissues. 

Actinomycosis is a very rare affection of the skin (less than 
three per cent, of all cases of the disease), the deeper tissues, 
especially the intestine, liver, lungs, and other viscera, being 
most frequently affected. 

In 1876 Bollinger recognized that the so-called osteo- 
sarcoma of the jaws of oxen was really due to a fungus, 
which Harz, from its morphology, named the " ray fungus," but 
as far back as 1845 Langenbeck described a fungus in connec- 
tion with a case of caries of the vertebrae. In 1877 Israel de- 
scribed a case in man, but left it for Ponfick, in 1879, t0 demon- 
strate that the affection in man was identical with that in 
animals, as described by Bollinger. Majocchi was the first to 
describe its occurrence in the skin. He divides cases into 
anthracoid and ulcero-fungoid. The fungus gets into the tis- 
sues generally by the mouth, especially along carious teeth; by 

* Literature. — Neumann's Atlas, Plate XIII., and Malcolm Morris, 
Lajicet, June 6, i8g6, give good colored plates of the disease on the face, 
and numerous references ; Pringle, Med. Chir. Trans., vol. lxxviii., 1805, 
of the skin over the ribs. Kopp's Atlas, Plate LXXV. Uncolored illus- 
trations of the face or neck have been published by Illich (loc. cit.) and 
Darier and Gautier, Ann. de Derm, et de Syph., vol. ii. (1891), p. 449. 
E. Ponfick, " Actinomykose des Menschen," Berlin, 1882, with colored 
plates. J. Israel, " Actinomykose des Menschen," Berlin, 1885. A. Illich 
" Klinik der Aktinomykose," Wien, 1892, with photographs and references 
to 569 communications. English readers, for a general account of the 
subject, may consult Hime's full abstract of Israel's monograph in New 
Syd. Soc., " Microparasites in Disease" (1886), and the observations of 
various authors in the Transactions of the learned societies; or " Actino- 
mycosis hominis,"by M. Skerritt, Amer.Jour. Med. Sciences, vol. for 1887. 
Crookshank, " Text-book of Bacteriology," fourth edition. T. D. Acland, 
" Actinomycosis and Madura foot," Art. in Allbutt's " System of medi- 
cine," 1897. References to date. Poncet et Berard, " Traite clinique de 
l'Actinomycose " (Paris, Masson etCie., 1898). Jour. Mai. Cutan., vol. 
xiv., April, 1902, contains abs. of several cases, and of an historical 
paper by Blanchard, showing that numerous cases by old authors were 
recorded but misunderstood. 



1340 DISEASES OF THE SKIN. 

some other portion of the digestive tract; or by the air pas- 
sages. The lesions excited by its presence usually reach the 
skin in some part of the face and neck, rarely affecting the 
chest or abdominal walls from the viscera. Only in a very few 
instances has there been proof or reason to believe that the 
skin has been primarily affected from without through some 
abrasion of its surface, and the hand has been thus affected, but 
usually it is the face or neck even then, the special Indian form, 
mycetoma, being of course excepted. From the time of en- 
trance of the fungus to its appearance on the surface, many 
weeks, months, or even years may elapse. In secondary in- 
volvement of the skin the lesions produced are remarkably like 
those of scrofulodermia, for which they have often doubtless 
been mistaken. The deep-seated actinomycetic tumor en- 
larges, suppurates, and as it approaches the surface the skin 
becomes red, livid, thinned, and undermined by suppuration, 
and fluctuating tumors are formed over the affected area, often 
with little or no pain, but pain, even severe, may be present; and 
then the skin at last gives way, either at one, or more often 
at several fistulous openings, a sanguineous serum or purulent 
fluid containing the characteristic yellow granules being dis- 
charged. 

If some of the pus is collected in a test tube and held up to 
the light, they appear as brownish or greenish-brown granules 
embedded in muco-purulent matter. They are from a small to 
a large pin's head in size, sulphur yellow by reflected light, and 
greenish-yellow or brown by transmitted light. The micro- 
scopical appearances will be presently described. 

In exceptional cases there is persistent boardlike infiltration 
without any softening or breaking down, or the induration may 
gradually subside without treatment. In Darier and Gautier's 
case, a woman, aet. twenty-five, nearly the whole cheek was 
occupied by a red nodular swelling, crusted in some places. 
The nodules, some of which were a third of an inch in diameter, 
were on a hard base, and some suppurated and broke down. 
The part was tender, but not otherwise very painful. As the 
clinical characters were not those of cancer, glanders, syphilis, 
or lupus, the pus was microscopically examined, and acti- 
nomyces found. Morris' case resembled the above, but was 
attended with great pain; both represent the anthracoid type. 



ACTINOMYCOSIS OF THE SKIN. 1341 

Pringle's case on the back represented the ulcero-fungoid 
type; there were enormous fleshy sarcomatous-looking out- 
growths of mottled purplish and yellow color. As he de- 
scribes it: " All the growths feel pulpy and fluctuating, and are 
not tender. Each growth presents at least one, usually several 
small crateriform ulcerative openings, from which a clear, 
rather sticky, fluid constantly exudes. In each of these 
ulcerative surfaces there is an accumulation of purulent fluid 
of pale yellow color, which is seen to contain innumerable tiny 
granular specks. There are also pigmented sunken scars, the 
remains of previous lesions." In man, with rare exceptions, the 
bones escape, unless there is secondary pus cocci invasion, while 
in animals the bones are always involved from the first. On 
the other hand, suppuration is absent in animals, while it is the 
conspicuous feature in man, although the amount in each focus 
is small. The openings are usually external on the cheeks. 
The course of the disease is, as a rule, chronic, with exacerba- 
tions, but it is occasionally acute, and the disease spreads both 
continuously and by metastasis. 

In the temporo-maxillary form great pain, and even trismus, 
may precede the tumor development, which, before the nodular 
development, is smooth and hard, but elastic, and the true 
nature of the disease would scarcely be recognized at this 
stage. 

Though, according to Poncet, the character of the pain which 
comes on at night, the early trismus often preceding the pain, 
the wooden hardness of the growth, and the absence of 
glandular enlargement are characteristic, the acute cases may 
resemble angina Ludovici, and may be fatal in a week. Chronic 
cases are fatal by extension to vital parts, such as the brain, 
lungs, or heart chiefly, where the disease has been allowed to 
run its course without recognition, or before the iodid of 
potassium treatment was known. 

Etiology. — Males more than females are affected, on account 
of their employment, and the majority have been young adults, 
but five years and sixty-five have been recorded. Although 
there is some evidence that the fungus is often derived from 
corn or hay, there is no definite proof yet of its origin. Some 
have had to do with cattle or horses, others have been in the 
habit of chewing straw or raw corn, and chewing malt appeared 



1342 



DISEASES OF THE SKIN. 



to be the cause in the case of Carless, but in many, neither 
occupation nor other circumstances have suggested the mode 
of origin. In exceptional instances it may be directly com- 
municated. Baracz of Lemberg reports the case of a cab-driver, 
in whom a tumor the size of a walnut formed over the left lower 
jaw, after the extraction of a tooth; an incision was made into 
the tumor, and the pus examined showed the ray fungus; 
shortly afterwards this man's fiancee came under observation 
with a similar but softer alveolar abscess, which also contained 
the fungus. Murphy of Chicago had a case in which the lower 
jaw of a woman was affected, and the history showed that her 
pet dog had died shortly before with a large swelling of the 
lower jaw. 

Poncet and others have reported similar cases of transmission 
from animals. In Midler's case a woman ran a splinter into 
her finger, and two years later an actinomycetic tumor formed 
at the site of injury, and the chip of wood was found in it. 

Guillemot's case was similar; a blow on the face with a piece 
of wood was followed in a few weeks by a tumor on the in- 
jured spot. It has also been attributed to meat and milk from 
infected animals, and other articles of food, such as potatoes, 
have been suspected. 

Pathology. — It has already been explained that the disease is 
due to the inflammation excited in the tissues by the ray 
fungus; it only remains, therefore, to describe its morphology. 

Anatomy. — The yellow granules above described have a center con- 
sisting of a mass of finely interwoven threads, from which others, equally 
fine, radiate and constitute the greater portion of the nodule. These 
threads, either singly, or after dividing dichotomously, swell out at their 
ends into club-shaped bodies, which being situated at the periphery of 
the mass, give it an irregular mulberry appearance. There is reason for 
believing that the central threads are the mycelium, and the club-shaped 
bodies the fructifying portion of the fungus, but the latter point is not 
yet definitely proved, as they are not found in artificial cultures. 

Crookshank* describes the history as follows: "The spores sprout suc- 
cessively into excessively fine straight or sinuous, and sometimes dis- 
tinctly spirilliform threads, which branch irregularly, and sometimes 
dichotomously. The extremities of the branches develop into club- 
shaped bodies, but it is difficult to say what further changes occur in 
them." 

* Lancet, January 2, 1898, p. 11, with colored plate of fungus and its 
cultures. 



ACTINOMYCOSIS OF THE SKIN. 



1343 



He thinks the fungus belongs to the basidio-mycetes. Crookshank 
recommends that the granules should be examined as follows: When 
simply transferred to a slide, and a cover-glass applied without pressure 
with a one-inch objective, they appear as spheroidal masses of a pale- 
greenish color; on gently pressing the cover-glass, they separate into 
characteristic wedge-shaped fragments of a faint brown color. With less 




Fig. 99. — A mass of actinomyces, showing the ray arrangement, the club- 
shaped bodies, and a thread of mycelium extending beyond the 
mass and after division expanding to form clubbed ends (after Pon- 
fick). The appearances depicted can only be seen by focusing up 
and down, so as to bring the several planes successively into view. 



pressure and careful focusing with |- inch, rosettes of clubs can be seen, 
while the characteristic clubs come out best when a thin layer in a drop of 
glycerin is examined with T a ¥ inch. Permanent preparations in glycerin 
can also be made. The best methods for staining are by Gram's method 
and eosin or orange rubin. This stains the central core of mycelium in 
the club blue, and its mucilaginous sheath pink or crimson. 

The threads in the center of the granule are also differentiated into an 
external sheath and protoplasmic contents. While staining brings out 



i 3 44 DISEASES OF THE SKIN. 

small interesting points, it is not necessary for diagnosis. The fungus 
can also be cultivated in nutrient media, of which glycerin agar is one 
of the best, and inoculated into bovine animals, but rabbits and dogs are 
comparatively insusceptible. 

Diagnosis. — Slowly developing, comparatively painless, sup- 
purating growths, in circles, groups, or moniliform lines in an 
adult, especially if in the skin near the jaws, with yellow points 
under the skin, and a tendency to open in several places like a 
carbuncle, should excite suspicion, and lead to the examination 
of the pus for the characteristic sulphur-yellow masses which 
are the only sure sign of the disease. The absence of lymphatic 
enlargement and the age would be against scrofulodermia, few 
cases occurring in children, and the occupation connected with 
horses or oxen, or with dried cereals, might furnish a significant 
hint. That the actinomycetes are not readily found in all cases 
Legrain's * case shows: the skin over the nodules was stretched 
and red, and small superficial abscesses formed in the neighbor- 
ing skin. On puncture a hard zone was felt round them, but no 
fungus detected, but scrapings of an abscess inoculated under 
the abdominal skin of a rabbit produced a hard nodule, in which 
the ray fungus was found microscopically, and further demon- 
strated by successful cultivation in bouillon, gelatin, and agar- 
agar. The inoculation in a rabbit is noteworthy, as Ponfick 
considered them insusceptible. Other conditions besides scrof- 
ulodermia produce apparently similar lesions to actinomycosis. 

Thus, in one of my cases, a farm laborer of middle age, 
there were closely aggregated nodular suppurating swellings all 
over the dorsum of one foot. Repeated microscopic and cul- 
tural examination showed only staphylococcus aureus, and per- 
sistent local disinfection of each lesion produced a cure; all the 
lesions were superficial. In another case I saw, a girl had an 
alveolar abscess which was followed by external suppuration, 
and it was treated before she came to the hospital by persistent 
poulticing. Under this the whole cheek was covered with pea- 
sized suppurations, but my colleague, Victor Horsley, was un- 
able to find the actinomycoses, either before or after scraping 
away the unhealthy granulations. 

The resemblances and differences from sarcoma need not be 

* Ann. de Derm, et de Syph., and abstract in Brit. Jour. Derm., vol. iii 
(1891), p. 399. 



ACTINOMYCOSIS OF THE SKIN. 1345 

further alluded to. Syphilitic gummatous infiltration might 
also be mistaken for it, and the effect of iodid of potassium 
would only confirm an erroneous view of specific origin of the 
lesion. Apart from microscopic examination an important dif- 
ference is that in the early stage of suppuration the pus of 
actinomycosis is thin and scanty, while that from syphilis is 
thick and often abundant. 

Its production of perityphlitis and other visceral conditions 
need not be gone into here. Under Mycetoma the clinical ap- 
pearances are contrasted with that analogous disease. 

The prognosis is good when there is early recognition, so 
that iodid of potassium can be effectually administered, or if 
the lesions are situated in a position where removal can be 
effectually accomplished, but it is ultimately fatal if left to itself. 

Treatment. — The discovery that iodid of potassium is almost 
a specific has almost revolutionized the treatment and prognosis 
of actinomycosis. It was first given for the disease in cattle, 
Thomassen having cured eighty per cent.; Morris' is a good 
case in point for the human subject. The treatment was begun 
six weeks after the appearance of the first lesion, during which 
time there had been rather rapid development, extending over 
the angle of the mouth, over the lower jaw, nearly to the ear; 
fifteen (afterwards increased to thirty) grains of iodid of potas- 
sium were given three times a day, and in ten days only traces 
of the fungus could be found, in three weeks the growth was 
only half the size, and in less than three months had disap- 
peared. The iodid was continued for three months longer, the 
patient remaining well. It is noteworthy that for the first 
three days of treatment the pain and discharge were increased, 
and then rapidly abated. The treatment may, however, fail if 
suppuration has already occurred or has spread to important 
parts, such as the base of the brain; some of Ransom's * cases 
may be referred to in this connection. It is said also that it 
does not destroy the fungus, but only the granulation tissue in 
which it is imbedded, and so, if there is an external opening, it 
permits the fungus to be discharged. It also very much dimin- 
ishes the extent and severity of an operation if one should be 
ultimately required. 

Locally the treatment consists in the early opening of ab- 
* Brit. Med. four., June 27, 1897, p. 1553 — eight cases, one of orbit. 
85 



1346 DISEASES OF THE SKIN. 

scesses, laying open sinuses, scraping out the diseased tissues, 
removing affected bone, and syringing thoroughly with anti- 
septics, such as iodin, one in a thousand or stronger of per- 
chlorid of mercury, or with carbolic acid. Rydigier treated two 
cases successfully with parenchymatous injections of iodids — 
a one per cent, solution of sodium iodid appeared the best; 
some local reaction ensued on the first injections. Accessible 
disease should be attacked at once by surgical means without 
waiting to see what the iodids internally will do. 



MYCETOMA.* 

Sytwnyms. — Fungus foot of India; Madura foot; Podelcoma; 
Ulcus grave; Tubercular disease of the foot. 

Definition. — An endemic disease affecting the foot or hand, 
attended with disintegration of the tissues, probably due to a 
variety of ray fungus. 

The earliest notices of the disease, according to Mansori, are 
due to Kampfer (1712), Godfrey of Madras (1843), Balingall 
(1855), and Eyre (i860), but Vandyke Carter's papers and mas- 
terly monograph (1874) form the foundation, and most of the 
superstructure, of our present knowledge. 

There are three varieties, the pale, the black, and the red, the 
pale being the most common, while the red is very rare. In 
the vast majority of cases the foot or leg is attacked, but some- 
times it affects the hand, and in rare instances the shoulders, 
sacro-iliac joint, knee, ankle, and scrotum. The neck and abdo- 
men are also on record. 

Symptoms. — In a fully developed case the foot is much swollen 
and distorted, the arch being broken down and the toes forced 

* Literature. — Vandyke Carter, "On Mycetoma; or, ' Fungus Foot of 
India ' " (Churchill: London, 1874), with many colored plates. Tilbury 
Fox, 3d ed., p. 468. "Skin Diseases of Parasitic Origin " (Hardwick), 
p. 62. " Endemic Skin and other Diseases of India," Fox and Farquhar's 
Report, p. 42, Appendix I., p. 18, Appendix IX., p. 215. "The Fungus 
Disease of India," Lewis and Cunningham's Report, Calcutta, September, 
1875. Crookshank's " Bacteriology," 4th ed., 1898. " Mycetoma as it 
occurs in America," Nevins Hyde and Serin, /our. Cut. and Gen.- Ur. Dz's., 
January, 1896, gives bibliography of modern researches. Manson, 
" Tropical Diseases," 2d ed., 1900, gives good resume. 



MYCETOMA. i 347 

apart and overextended, so that the sole is convex from behind 
forwards. All over the surface are numerous pea-sized mam- 
millated eminences, in the center of which is the orifice of a 
sinus leading to a cavity situated at various depths in the foot 
substance, and giving exit to a thin sero-purulent discharge, 
containing rounded granules, like " fish-roe," of a grayish or 
yellowish color, or smaller black particles, or the granules may 
be aggregated into pea-sized masses. In rare instances the 
granules are pink or reddish in color. These granules also stud 
the surface of the eminence round the sinus. 

The disease appears to be superficial at first, and may attack 
only a toe or finger, but the mode of commencement varies. In 
some cases there is at first very little swelling or alteration in 
color, except perhaps slight congestion; in others there may be 
a local induration or a papule, pustule, or nodule, either super- 
ficially or deeply seated, at some part of the foot, firmer, larger, 
and more diffused and less painful than a boil, which, when 
opened, discharges ordinary pus at first, but later on granules 
like poppy seeds, or the peculiar black material to be presently 
described, mingled with the discharge. In other cases there is 
a blackish or bluish mottled discoloration like tattoo puncta, 
before any wound of the skin appears. 

Course. — The disease progresses so gradually that it takes 
several years for the whole foot to become disorganized, though 
it is generally useless for progression after a year or two, but 
its course and duration are very variable. Cases have been 
recorded lasting as long as twenty-six or even thirty years ; and, 
on the other hand, a considerable portion of the foot is some- 
times involved in the course of a year or less, but three to seven 
years is a common period. In some instances the tumor is 
very large, increasing the bulk of the foot to four or five times 
the normal size, while the leg wastes and increases the con- 
trast. Sometimes the disease spreads upwards to the ankle or 
even knee, and it has been known to commence in the knee. As 
a rule it is not painful, but its bulk and shape interfere with 
walking. 

Etiology. — The disease is endemic in certain parts of India, 
especially in Madura, but is not limited to any particular soil or 
geological formation. It has also been observed in Constanti- 
nople, Senegambia, Cochin China, Africa, Syria, and rarely in 



1348 DISEASES OF THE SKIN. 

Italy, the United States, and Canada, Guiana, and Chili. It is 
far more common in males than females, and may occur at all 
ages, though it is rare below puberty. A history of a previous 
attack of guinea-worm disease is present in a good many, but 
no etiological connection can be shown. It appears to be more 
common in those who work barefoot in the fields.* Not infre- 
quently the disease is said to date from an abrasion or other 
slight injury, especially the pricks of thorns, and Bocarro states 
that the thorns of acacia Arabica have been found in the dis- 
eased tissues, but equally often the origin is quite obscure. 

Pathology. — Vandyke Carter long ago found a fungus in the 
black variety, which was named after him Chionyphe Carteri, 
and to which he attributed the disease; but as none could then 
be found in the pale form, it remained doubtful as to whether 
it was the true materies morbi. In 1886 he pointed out, as 
Ponfick had previously done, how much mycetoma clinically 
resembled actinomycosis hominis. Since then, owing to im- 
proved methods of staining fungi, this conception of their rela- 
tionship, if not identity, may be considered as proved, thanks to 
the researches of Crookshank, Kanthack,f Hewlett,^ Boyce § 
and Surveyor, Vincent, || etc. 

Clinically there are several important differences between 
mycetoma and actinomycosis hominis as seen in Europe; viz., 
actinomycosis is almost unknown in India, and mycetoma in 
Europe. Mycetoma is invariably a chronic local disease; the 
internal organs are never affected; the constitutional symptoms 
are always very slight; it never attacks the cervical and 
thoracic regions, which are the favorite seats of actinomycosis; 
the sulphur-colored bodies of actinomycosis have never been 
detected in mycetoma; nor have the black, red, and pale varie- 
ties of mycetoma been found in actinomycosis. 

The general opinion now is that the pale variety contains a ray fungus, 
but whether identical with the European actinomycosis or not cannot be 
proved, as the pleomorphism of that fungus is well known; sometimes 
mycelium only is present, at others only clubs. Surveyor and Boyce 

* Legrain found the pale variety only, in Kabylia, in Algeria. 

f Path. Trans., vol. xliii., 1893, and Lancet, July i6 x 1892. 

\ Ibid., July 2 and August 27. 

%Brit. Med. Jour., September 22, 1894. 

|| Annates de Derm, et de Syph., vol. vii. (1896), p. 1253. 



MYCETOMA. i 349 

have shown that the mycetoma fungus grows exceedingly slowly in a 
hydrogen atmosphere, while actinomyces grow rapidly; moreover, the 
mycetoma prefers vegetable to animal media. With regard to the black 
variety, the fungus most readily found appears to have the characters of 
an aspergillus with coarse septate mycelium, but having regard to the 
clinical resemblance of the black and white varieties, it has been sug- 
gested that there has been a mixed infection, the ray fungus being 
obscured by the aspergillus. Vincent cultivated a new fungus and called 
it the streptothrix madune. The best medium is a two per cent, infusion 
of hay; or potato ioo, gelatin 9, glycerin 4, grape sugar 4. Kanthack 
says that he has found some ray fungus amongst the aspergillus form of 
the black variety, and that there are transition forms between the pale 
or perfect type and the black degenerated or structureless type. The 
association of the black and white granules in the same case is rare, but 
has been noted by Lewis, * Cunningham, and Boccaro. The disease can- 
not be proved to be transmissible to the lower animals by inoculation of 
either Vincent's streptothrix or of the mycelial fungus found in the black 
variety. 

To see the fungus, Kanthack's plan is to soak the tissue in ether or 
chloroform, and wash well in caustic potash, when small round bodies 
are left in, with rays which appear and stain like those of actinomyces. 
Hewlett recommends the Ehrlich-Biondi stain. 

Boyce and Surveyor used the following method for the black variety: 
Boil the particles for a few minutes to one hour in concentrated caustic 
potash, then transfer to distilled water, when a mycelial fungus could be 
seen. Or decolonization may be effected by washing the tissue for a 
minute with eau de Javelle, and then it may be stained as for actino- 
myces. 

Anatomy. — On making a longitudinal section of a Madura foot in an 
advanced condition, the limb is found to be tunneled in all directions by 
sinuses, which may pierce the bones even, and lead to spherical cavities, 
either single and blind at one end, or compound and communicating with 
other cavities and sinuses. The whole segment of the limb is softened 
from fatty degeneration. 

The single cavities may or may not be superficial; the compound ones 
are deep in the foot substance, and may be either in the bones or soft 
parts and ramify in every direction. The cavities and channels are lined 
by a fibrous membrane, and contain granules, separate or aggregated into 
mulberry-like masses, compared to fish-roe; these maybe whitish-yellow, 
brown, or black, and in rare instances are red, abundant in the discharge, 
and not only occupy the cavities, but the sinuses, studding the surface 
of their walls. 

The differences between the black and pale varieties appear to be in 
the presence or absence of this black material, and in the fungus elements 
in the tissues and in the discharge. 

*Crookshank, " Bacteriology," 4th ed., gives a more detailed review of 
the whole evidence; also in Lancet, January 2, 1897, p. 17. 



1350 DISEASES OF THE SKIN. 

The tissues of the foot are much altered, so that there is a general con- 
fusion of parts, owing to absorption of the bones and fibrous tissues, and 
thickening of the soft parts. The muscles are the least altered, and in 
some cases the bone substance remains healthy all round the channels 
with which they are pierced, while, on the other hand, the bone sub- 
stance of the tibia and fibula has been found softened when the limb has 
been amputated apparently well beyond the disease. Cunningham attrib- 
utes most of these changes to a peculiar endarteritis obliterans, the 
fungus being, he thinks, a secondary invasion, especially as in some 
cases the clinical appearances are classical, but there are no fungus 
elements to be found. 

Diagnosis. — When once the sinuses are formed and the dis- 
charge of the pale fishroe or black gunpowder-like material has 
ensued, there can be no difficulty in diagnosis. And the black 
granules under the skin before ulceration has occurred are al- 
most equally suggestive. In the early stage, when it com- 
mences with a vesicle or pustule, the idea of the presence of the 
guinea-worm may suggest itself; but when the abscess and sinus 
form, the diagnosis is cleared up, except where the two parasites 
coexist. 

Prognosis. — Spontaneous recovery is unknown. The disease 
is slowly progressive, until complete disorganization of the 
tissues is produced, and the patient is encumbered with a bulky 
and useless limb. 

Treatment. — Only complete removal of the diseased tissue is 
of any avail. In the early stage, if the affected area is super- 
ficial, scraping with a sharp spoon may be successful, or the re- 
moval of a finger or toe, while the disease is limited to it, may 
suffice; but when advanced, amputation of the limb, well above 
the diseased area, is the only course. The analogy with 
actinomycosis suggests the administration of iodid of potas- 
sium, in intermediate cases. 



BLASTOMYCOSIS.* 

Definition. — Miliary abscesses in the skin, due to the presence 
of blastomycetic elements, leading to granulomatous ulcerative 
lesions with papillary outgrowth. 

Gilchrist in May, 1894, and shortly after, Buschke in Busse's 

case, were the first to find the organisms in the pus and sec- 

* There is a good article of Gilchrist's in " Reference Handbook of the 



BLASTOMYCOSIS. 135 1 

tions of the skin; but Busse, six months later, was the first who 
showed their significance, and that the disease was due to the 
invasion of the tissues by saccharo-mycetic fungi. 

Buschke inoculated Busse's patient and reproduced the dis- 
ease with acnelike nodules going on to crateriform ulcers. 

The clinical and pathological features have been further 
worked out chief!} 7 in America, where most of the cases have 
been observed by Gilchrist, Curtis (in France), Wells, Hessler, 
Brayton, Hyde and Hektoen, Hyde and Ricketts, Montgomery 
and Ricketts, Stelwagon,* etc. A doubtful case has been re- 
ported by Azua of Madrid. No case has been hitherto recog- 
nized in England, so I give the following description partly in 
the words of Gilchrist, supplementing them with Hyde and 
Montgomery's observations, as they have most studied the dis- 
ease, no less than eleven cases having occurred in Chicago. 

Symptoms. — The initial lesion is a split-pea-sized nodule, which 
after a time becomes pustular and breaks down into an ulcer. 
This extends in one or several directions, and others may form 
in the neighborhood. As the ulcer enlarges, in nearly all cases 
there is papillary growth, sometimes verrucose, sometimes 
f ungating, in one case a cauliflower growth projected an inch. 
A thin mucoid discharge, often offensive, is usually present, or 
this may be temporarily stopped by the scabbing over of the 
lesion, but the scab is soon thrown off, and the thin pus dis- 
charges, or can easily be squeezed out from between the 
papillae. In this pus the blastomycetes can easily be found by 
the addition of a little liquor potassae as doubly contoured re- 
fracting budding bodies. In many cases pus cocci are also 
present, but these can be eliminated in cultures by Hektoen's 

Medical Sciences," 1901, p. 412, from which I have largely quoted. There 
is full bibliography to 1900, inclusive, and still later in Brit. Med. Jour., 
October 25, 1902, p. 1321, with illustrations, 

* In Amer. Jour. Cut. Dis., vol. xix. (1901), January No., are cases by 
Dyer, Montgomery, Hyde, and Ricketts, with numerous illustrations. A 
corrected table of cases by Hyde is in March No., p. 129, also a case by 
Brayton and Golden, p. 152. Stelwagon, Amer. Jour. Med. Set'., Feb- 
ruary, 1901, adds another case. Also J. Meneau. " Sur la Blastomycose 
Cutanee," Annatesde Derm, et de Sypk., vol. iii. (1902), p. 577. Full 
abs. Brit. Jour. Derm., vol. xiv. (1902), p. 393. A good general review 
and bibliography. A. Buschke, "Die Blastomykose," " Bibliotheca 
medica." (Erwin Nagele, Stuttgart, 1902). 



35 



DISEASES OF THE SKIN. 



method of adding a weak solution of potassium iodid to the 
culture medium, which kills the staphylococci and leaves a pure 
culture of the fungus; but the fungus is pyogenic, as pure 
cultures can often be obtained from the pus without this. The 
diseased patch always has a well-defined raised edge, is only 
slightly infiltrated, for the lesion is always superficial, and in 




Fig. ioo. — Blastomyces. X about 800. " Drawn from a series of sec- 
tions of a piece of tissue from a case of blastomycetic dermatitis 
(' coccidoides '), for which I am indebted to Dr. Howard Morron of 
San Francisco, a, Blastomyces, with central granular portion; b, 
budding cell; c, cell dividing by segmentation; d, budding of the 
fungus. This appearance was only found in one section, and rarely 
occurs in the tissue; e, giant cell formation around blastomycetes;/", 
infiltration of piasma cells and leukocytes." (From Macleod's " Path- 
ology of the Skin." 

very chronic cases there is a certain amount of healing with 
atrophic scarring. 

The general aspect is that of a scrofulodermia with papillary 
growth, or of lupus verrucosus; cases like yaws (Dyer) and 
lupus vulgaris (Gilchrist, Stokes) have also been observed. The 
lesions are usually multiple, as the patient inoculates himself 



BLASTOMYCOSIS. 1353 

from one place to another. It chiefly affects the face, hands, 
and neck, i. c, the uncovered parts, but the thigh is also a 
common starting-point, and no part is exempt; it may extend 
indefinitely. One case (Anthony Herzog) lasted twenty years, 
and involved almost the whole left extremity, without affecting 
the general health and with very little pain, but secondary septi- 
cemia and tuberculosis have occurred. In only two cases has 
there been glandular enlargement, and in Coates' case it was 
probably from another cause. 

Pathology. — The disease is due to the presence of blasto- 
mycetes * in the skin. These set up miliary abscesses in the 
epidermis and upper part of the corium, and in these the fungus 
elements f can be found, usually in budding pairs, but also 
singly and in groups. Secondary changes are : In the epidermis, 
more or less destruction of the horny layer; enormous over- 
growth of the prickle-cell layer with branching downgrowths; 
in the corium there is infiltration with leukocytes, endothelial 
and plasma cells. In subacute cases there are giant cells, and 
in chronic ones there is a pseudo-tuberculous structure. 
Buschke says that all the changes are of inflammatory origin. 

Diagnosis. — Hyde and Montgomery say that the diagnosis of 
blastomycosis and lupus verrucosus can only be made with cer- 
tainty by the microscope and cultures, but in general that lupus 
verrucosus is slower of evolution, more often limited to small 
areas; has a more distinct violet halo, and is more often about 
the lower forearm and ankle. 

It closely resembles so-called protozoic infection, which is 
a variant of blastomycosis. 

It may have to be distinguished from lupus vulgaris, lupus 

* Gilchrist. Stokes, Curtis, Hyde and Hektoen, Montgomery, and 
Ricketts have inoculated animals, and have produced lesions from which 
the fungus has been recovered and cultivated. The organism grows in 
all ordinary media, but especially well on potatoes and beer-wort agar. 

•f Hyde and Montgomery recommend methylene blue as the best stain, 
but the fungi can be easily seen in sections stained with hematoxylin and 
other common stains. They are seldom intracellular. They form round, 
oval, or slightly irregular bodies with a well-defined, double-contoured, 
homogeneous capsule, and a finely or coarsely granular protoplasm 
separated from the capsule by a clear space. Mature organisms have a 
diamater of from 7 // to 20 fi, though smaller and larger organisms are 
seen occasionally. Budding forms in all stages and organisms in unequal 
pairs are always to be found. 



i 3 54 DISEASES OF THE SKIN. 

papillomatosus, and other vegetating forms of disease, syphilitic 
or otherwise, including yaws, and from epithelioma. If the 
possibility of this disease be borne in mind the microscope and 
cultures will be decisive. 

Prognosis. — In only one case hitherto, that of Busse-Buschke, 
has it infected any other organs than the skin, and that case was 
fatal. Montgomery also had a fatal case which had been diag- 
nosed as acute miliary tuberculosis. On the skin, if allowed to 
go on unrecognized, great destruction and disfigurement may 
be produced, but it is fairly amenable to treatment. It may go 
on for an indefinite time. 

Treatment. — Bevan has discovered that blastomycosis, like 
actinomycosis, is amenable to large doses of iodid of potassium, 
but Hyde says that, although great improvement occurs, per- 
fect cure is seldom obtained. Meneau thinks there are two 
classes of cases, a, those due to a yeast, and b, those due to 
a mold fungus. The yeast cases run a more rapid and virulent 
course with abundant organisms, but are more amenable to 
iodid of potassium than the mold form. Small areas may be 
excised and large ones curetted, and Gilchrist recommends that 
nitrate of silver should be applied after curetting. 

A closely allied fungus disease was described first by 
Wernicke * of Buenos Ay res in 1890, and then by Rixford and 
Gilchrist, and was thought by these observers at first to v be a 
coccidial disease and called protozoic dermatitis. Ophuls and 
Mofntt, however, have shown that it is due to fungus elements 
very like those of blastomycosis. 

Only six cases were known up to 1902, and all had been 
fatal, internal organs having been affected. All were men, and 
four had lived in adjacent valleys of California, Santa Clara, 
and Jonquin. Two have been in Buenos Ayres. The origin has 

* Wernicke, R., Translation from Buenos Ayres Jour., 1890, in Jour, 
de Micro grap "hie (Paris, 1891), vol. xv. Centralbl.J. Backt. u. Parasit., 
vol. xii., 1892, Trans. Other references are: Rixford and Gilchrist, Re- 
print from Johns Hopkins Hospital Reports, vol. L, 1896. A highly 
illustrated and valuable monograph on this and blastomycetic dermatitis. 
Posados, A., " Psorospormosis Infectante Generalizada, Buenos Ayres," 
1897-1898. Montgomery, D. W., Brit. four. Derm., vol. xii. (1900), p. 
343, with good photograph. Full references to date. Ophuls, Phil. 
Med. Jour., 1900. Seeber, G. R , Thesis, University of Buenos Ayres, 
1900. 



BLASTOMYCOSIS. i 355 

not yet been traced. In the skin the resemblance of the lesions 
to those of blastomycosis is very close. 

Clinically, there are papillomatous and verrucose lesions (not 
in Ophiils and Moffitt's case) from which pus can be squeezed 
out, and pathologically, " there were the typical marked epithelial 
hypertrophy; the numerous miliary abscesses in which the 
organisms are present, and the tuberculous-like formations in 
the corium as well as the numerous plasma cells " (Gilchrist). 
He also says that the protozoa-like bodies developed by sporu- 
lation, the organism dividing up gradually into about one hun- 
dred spores, which were liberated by the bursting of the 
capsule. 

Ophiils showed that when animals were inoculated with the 
fungus, the sporulating forms were reproduced, and from them, 
in a hanging drop of bouillon, mycelium was developed. In 
brief, it appears that the two conditions are due to the same 
organism, but that in blastomycosis multiplication is by bud- 
ding, and the lesions are limited to the skin, while in the 
so-called protozoic dermatitis, multiplication proceeds by sporu- 
lation and visceral implication may follow with fatal results. 

No treatment hitherto employed has appeared to have any 
effect on the fatal progress of the disease. Iodid of potash and 
mercurial inunction were both well tried in Montgomery's case 
without any visible result. 

Sporothrix. Species of this organism are said by Schenk and 
Hektoen,* and by Perkins, f to have produced obstinate cutane- 
ous abscesses in two cases, which started in the index finger 
and produced subcutaneous nodules and abscesses along the 
lymphatics of the arm. 

The Papulo-Ulcerative, Follicular, Hyphomycetic disease 
described by Duhring and Hartzell J may also be mentioned 
here. The disease had been present for three years on the side 
of the neck of a lad of fifteen, and resembled " a mild expres- 
sion of lupus verrucosus." There was also a slight develop- 
ment on the forearm. The patches were rounded or crescentic, 
made up of discrete and confluent papules, some scaly or 

* Johns Hopkins Hosp. Bull., December, 1898. 
\Jour. Exper. Med., vol. v. (1900), No. 1. 
\Amer. Jour. Med. Set., March, 1895. 



1356 DISEASES OF THE SKIN. 

crusted. Scarring was present in some places. Sections 
showed a cavity wdiere a hair follicle had been destroyed con- 
taining mycelium and spores 1-2500 of an inch in diameter. 

I record the following case, in the hope that it may lead to 
further investigation on the part of those practicing in China 
and similar climates. 

A naval officer contracted the affection four years before I 
saw him off the China coast. 

It consisted of raised brownish-yellow rings chiefly in the 
hairy parts of the face, but he also had a ring on the scalp over 
the ear and over the left scapula. I regarded it as due to a 
vegetable parasite, and anti-parasitic treatment kept it under, 
and some of the lesions had disappeared, but after two years' 
treatment there were still three rings. The hairs of the beard 
on the rings pulled out easily without root sheath, but no 
fungus could be discovered after repeated examination. 
Patrick Manson and the members of the Dermatological Society 
saw the case, and also thought it was due to a deep-seated 
vegetable parasite. 



CLASS XI. 
ANIMAL PARASITES OF THE SKIN. 

The most important animal parasites of the human skin, 
either from their frequency or the character of the lesions, are, 
in Europe: The itch acarus; lice of the head, clothes, or pubes; 
bugs and fleas; and in tropical countries: The guinea-worm, the 
chigoe, and mosquitoes. There are, however, a large number 
of other parasites which attack man more rarely. These have 
been divided by Geber, in his valuable article in Ziemssen's 
" Handbook of Skin Diseases," into three classes. 

I. Stationary parasites which prey almost exclusively on the 
human skin. 

II. Temporary or occasional parasites: (a) sexually mature; 
(b) in their larval condition. 

III. Accidental parasites which do not voluntarily attack 
man, but when on the skin injure it from the instinct of self- 
preservation. 

The following list is borrowed from his articles; but, long 
as it is, it is not quite complete: 

I. Stationary Parasites. 

Sarcoptes scabiei hominis, itch mite. 

Demodex (acarus) folliculorum hominis. 

Pediculus: (a) Pediculus capitis, head louse; (b) Pediculus vestimenti, 

clothes louse. 
Phthirius pubis, crab louse. 
Pulex irritans, flea. 

II. Temporary Parasites. 

i. In sexually mature condition. 

Sarcoptes scabiei communis. 

Dermanyssus avium, bird mite. 

Ixodidce: (a) I. ricinus, reduvius, ticks; (b) Argas reflexus, Persicus, 

Americanus. 
Cimex lectularius, bed bug. 
Pulex s. Sarcopsylla penetrans, sand flea. 
Tabanidae, horse flies; Tabanus, Chrysops ccecutiens, Pangonia. 

1357 



1358 DISEASES OF THE SKIN. 

Culicidae, Culex pipiens, Simula colombacencis, S. pertinax. 
Hirudinese; Hirudo medicinalis, officin., and others, Hemataria Mexicana. 

2. In larval condition. 

Cestoidea: Cysticercus cellulosae. 

Echinococcus, bladder worm. 
Trematoidea: Distoma hepaticum, liver fluke. 
Nematoidea: Filaria medinensis. 

Filaria sanguinis hominis. 
Oxyuris vermicularis. 
Leptodera. 
Muscidae: (a) Musca domestica, cadavarina, vomitaria, and Lucilia Caesar, 
(&) Sarcophila Wohlfarti (Portschinsky); Sarcophaga carnaria 

To these may be added Lucilia hominivora in America; 
Stomoxys calcitrans; Glossina morsitans, known in Central 
Africa as tsetse, etc. 

CEstridae: Hypoderma (ver macaque in Cayenne), species of 
Cuterebra; Dermatobia (CEstrus humanus, Humboldt); and 
Gastrophilus. 

III. Accidental Parasites. 

Species of Dermatodectes and Symbiotes (Gerlach). 

Leptus autumnalis, harvest bug. 
Kritoptes monunguiculosis. 
Clothilia inquilis, book worm. 



SCABIES.* 

Synonyms. — Itch; Fr. t Gale; Ger., Kratze. 

Definition. — A contagious disease due to an animal parasite, of 
the suborder acarus, characterized by a special lesion due to the 
burrowing of the female, and by multiform lesions from 
scratching. 

Scabies is an extremely common disease among the poor in 
England, and not rare in the better classes, constituting in my 
experience 8 per cent, in hospital, and 1.2 per cent, in private 
practice. 

In Scotland it is still more common. McCall Anderson met 
with it in one-fourth of his hospital cases, and in 4.4 per cent. 

* Bourguignon Delafond, " Traite pratique d'entomologie et de patho- 
logie de la Psore ou Gale," 1862. 



SCABIES. 1359 

in private practice. On the other hand, it used to be com- 
paratively rare in the United States, but has increased in a few 
years from less than 1 per cent., according to the Dermatologi- 
cal Association statistics, to 5.39 in 1891. Wliite of Boston 
notes an enormous increase there, from nine cases in 1880 to 
7.38 per cent, in 1891, while Stelwagon claims an even higher 
percentage for Philadelphia; in other cities the proportion is 
less. On the Continent it is very common. 

Symptoms and Pathology. — The clinical picture of scabies is 
made up of two elements: the burrows, or cuniculi, and the 
attendant inflammation excited directly by the acarus scabiei; 
and indirectly, the lesions produced by scratching, and the 
modifying influences of pressure, friction, etc. The result is 
a great multiformity of lesions, which, combined with their dis- 
tribution, is in itself suggestive of the nature of the disease, 
and enables a practiced eye to detect a well-marked case at a 
glance. 

In order to understand the process it must be premised that 
the male wanders free on the surface or is entangled beneath 
the crusts, and, with the exception of impregnation, takes no 
part in the production of the disease, the female alone being 
responsible for all the symptomatic eruption. When placed on 
the skin she burrows into it with her head, the bristles on her 
hind legs tilting her up, so that the head is inclined to the skin 
and penetrates below the surface, it is said, within half an hour. 
Then the impregnated female lays an egg, tunnels farther, lay- 
ing one or two eggs almost every day, amounting to about 
fifty altogether, soon after which she dies, having lived alto- 
gether about two months. The ova take from five to fourteen 
days to hatch out; but the way the newborn acarus reaches the 
surface is not certain, the most probable being that, the burrow 
being oblique, and the oldest end being nearest the surface, in 
the natural course of exfoliation of old epidermis, the most 
mature ovum reaches the surface first; thus the young acarus 
gains its freedom, and is ready to commence a new life cycle. 

The female selects generally the thinnest part of the skin, 
such as the web between the fingers and other parts of the 
hand, the flexures of the wrist, axillae, fork, and penis, and other 
parts of the genitals; but in long-standing cases, among the 
unwashed, no part is exempt except the head and face, which 



1360 DISEASES OF THE SKIN. 

are never attacked in this country, except in infants in arms. 
The marks of scratching are, however, much more general, and 
exist in all readily accessible parts. In men the pruritic erup- 
tion is mainly on the anterior surface, from the level of the 
nipple to the knees, and posteriorly, only on the buttocks. In 
women and children the arrangement of their clothes allows 
them to get at the lower part of the back, and the signs of 
scratching there are as well marked as in front. 

When the skin is first penetrated by the acarus, inflammation 
is often set up, and a papule, vesicle, or pustule is the conse- 
quence. These papules or small vesicles, individually indis- 
tinguishable from eczema vesicles, are the most common form 
of eruption, but the inflammatory symptoms are absent in many 
burrows. The tract extends and forms a sinuous, irregular, or 
rarely straight line, which in very clean people is white, but, as 
a rule, is brownish or blackish from dirt being entangled in the 
slightly roughened epidermis; the length of these burrows is 
generally from an eighth to half an inch, but occasionally much 
longer, Hebra having noticed one four inches long. When a 
pustule is formed, part of the burrow lies in the roof, but the 
acarus is always well beyond the pustule or vesicle, or, if there 
is none, lies at the far end, and with a lens may often be dis- 
cerned as a white speck in the epidermis. The degree and 
number of inflammatory lesions vary much; there may be no 
inflammation at all about many burrows, or the whole hand, 
especially in children, may be covered by pustules, vesicles, or 
papules, and indeed a pustular eruption on the hands is always 
strongly suggestive of scabies; there is, however, no grouping 
or arrangement of any of the eruptions, as in eczema, the lesions 
being scattered about irregularly. It must be remembered that 
burrows are not always present, from various causes. If the 
disease is recent, it may not have got beyond the papular or 
vesicular stage, while in washerwomen, bricklayers, or others 
whose hands are constantly soaked in water or alkaline fluids, 
or who have to scrub their hands violently, the burrows become 
destroyed. The eruptions due to scratching have already been 
described in the description of the " scratched skin," and com- 
prise excoriations, erythema in parallel lines, eczema, im- 
petiginous or so-called ecthymatous eruptions and wheals, and 
the inflammatory scab-topped papules often left after the sub- 



SCABIES. 1361 

sidence of the wheals, especially in children. In carmen, cob- 
blers, tailors, and others who sit on hard boards for hours to- 
gether, pustular and scabbed eruptions, situated over the ischial 
tuberosities, are so abundant and constant as to be practically 
diagnostic of scabies in such people. Similar eruptions may be 
seen where there is friction from trusses, belts, etc. 

Variations. — In a few cases the vesicles and pustules on the 
hands are very like variola. In the variety known as Nor- 
wegian itch,* which is seen in its highest intensity in lepers, in 
whom the disease has been allowed to grow unchecked, and in 
people among whom washing is indulged in with the utmost 
caution, the lesions are not limited to any special regions, even 
the face becoming involved, and the number of acari is very 
great, owing to the protection afforded by the extensive crust- 
ing. The palms and soles are covered with thick and leathery 
crusts, with yellow horny outgrowths of epidermis; the nails 
degenerate, splitting, breaking, and shriveling from damage to 
the matrix. On the face, ear, and scalp the crusts are pustular, 
containing acari and their debris in great quantity, just like the 
mange or scabies of animals, especially that of sheep, camels, 
and rabbits. 

In a young nodulated leper under my care, who sweated pro- 
fusely for some months before his death, his limbs were thickly 
incrusted with an epithelial, mortarlike deposit, which was 
ascribed to the sweat disturbance. Scabies was never sus- 
pected, as the itching was never very great, and he had none of 
the usual signs; but when he died I sent some of the skin to the 
pathological laboratory of University College, and Boyce dis- 
covered that the epidermis and incrustations were simple rid- 
dled with acari in all stages. 

Children. — In infants in arms the scabies eruption may be 
present over the face and scalp, from the child being held close 
to its infected mother; for a similar reason burrows are often 
found on the hips and feet of infants, infected from the mother's 
hand. Acute inflammation is much more easily set up in chil- 
dren; consequently pustular eruptions are much more sommon 
and extensive, both directly due to the irritation of the acarus, 
and also from impetigo contagiosa (ecthyma), resulting from 
scratching; urticaria is also more easily excited. 
*Syd. Soc. Atlas, Plate XXVII. 
85 



1362 



DISEASES OF THE SKIN. 



Etiology. — The disease is always propagated by the deposition 
of an impregnated female upon the skin, but, as a rule, it is only 
after prolonged contact with infected people or objects, as in 
occupying the same bed, handling an infected person's tools, 




Fig. 101. — Mature pregnant female acarus. X 300 (Kaposi). 
In the interior of the abdominal cavity there is a mature ovum ready to 

make its escape. 

which are familiar examples; but I believe that it is very rare 
for ordinary contact, like shaking hands, to be the cause of con- 
tagion. No age, sex, or condition is exempt from it, but dirty 
people are more liable to it, as the acarus has a better chance 
of burrowing before it is disturbed. 

Anatomy. — The description of the animal is sufficient here. It must be 
remembered jthat an acarus is not an insect, but having eight legs, belongs 
to the sub-order acari of the class Arachnidae. 

The female is just visible to the naked eye as a minute, white, shining. 



SCABIES. 



i3 6 3 



roundish body, one-eightieth to one-sixtieth of an inch long (.3022 to 
4322 mm.), and about two-thirds of its long diameter in width. Attached 
to its conical, stumpy legs are four suckers anteriorly and four setae or 
bristles posteriorly, one to each limb; on the back are numerous trans- 
verse striae and serrated lines, with a few short, nail-like setae; while on 
the under surface are the legs, a few setae, and sometimes an ovum 
(Fig. 101). 

The male is about two-thirds the size of the female, has a small sucker 
on each of the inner posterior pair of legs, for the purpose of copulation, 
and a well-marked genital organ, consisting of a chitinous framework, in 
the shape of a horseshoe, which supports the penis (Fig. 102). 

The larva has at first only six legs, and it is not until after its second or, 




Fig. 103. — Larval acarus with only 
Fig. 102. — Male acarus. X 300 six legs and comparatively few 
(Kaposi). bristles (Kaposi). 



as some say, its third molt that it is fully developed and has its full 
complement of eight legs; it, too, burrows a short distance while it is 
undergoing its molts (Fig. 103). When a cuniculus is snipped out with 
scissors and examined, the ova are found in it in all stages of develop- 
ment, with fecal and other debris, with the most mature ovum at the 
oldest end of the burrow and the mother acarus at the other (Fig. 104). 

Contrary to the usual statement, Torok, who examined seven burrows, 
stated that the burrow was in the lowest part of the middle horny layer, 
and not in the rete. In the case of the leper before described this was 
correct for the great bulk of them, but here and there one acarus among 



1364 



DISEASES OF THE SKIN. 




Fig. 104. — A burrow formed by an acarus within the epidermis, contain- 
ing a female acarus with the head directed to the blind end of the 
burrow. In the acarus is an ovum. Behind the acarus, and in a row 
one after the other, with their long axis placed transversely to the 
long axis of the burrow, there are ten ova. In the three youngest of 
these the contents have already undergone subdivision. From the 
fourth to the tenth the progressive development of the young acari, 
in relation to the age, may be seen, beginning at the head, and, at the 
tenth ovum, the development is almost complete. Between the ova 
of the acari are black irregularly shaped fecal masses. 



SCABIES. 1365 

a score would be found in the upper part of the rete. Schiscka * states 
that while the burrows are always in horny layers, when the skin is thin, 
the acarus penetrates to the rete, and that then cornification of the rete 
cells round the acarus immediately occurs, and thus the burrows are 
always surrounded by horny cells. The inflammatory papules are the 
result of the penetration of the acarus into the rete and the irritation they 
set up in the papillary layer. 

Diagnosis. — The diagnosis of scabies may be very easy or 
very difficult according to the development of the disease and 
the cleanliness, or otherwise, of the patient. In a well-marked 
case the characteristic feature is the presence of papules, vesi- 
cles, or pustules, chiefly on the hands, wrists, and genitals, indi- 
vidually looking like eczema, but, as a whole, scattered rather 
than grouped, a very important point: e. g., one or two vesicles 
only would be present on the web of the fingers in scabies, 
while in eczema there would be a patch of small vesicles. In 
such a case close investigation would probably discover the 
characteristic burrow, and from this an acarus may be picked 
out by finding the more recent end of the burrow, from its 
being a little redder, and then with a needle the epidermis may 
be broken over the little white speck and the point inserted, 
when the acarus generally clings to it. A good place to hunt 
for the burrows is the inner border of the hand, the fingers, 
and the body of the penis. If the patient is a male and can be 
stripped, the distribution of the scratch-marks, mainly from the 
level of the nipple to the knees, and the ecthymatous pustules 
on the buttocks, of those who sit on hard seats, are equally 
suggestive of scabies, and in a general survey the multiform 
character of the eruption ought to excite suspicion. 

Prognosis. — Scabies is always easily curable if sufficient pre- 
cautions are taken against reinfection. 

Treatment. — The treatment is simple and effectual, but re- 
quires a little care in its performance, something more than a 
prescription being necessary. There are two evils to be 
avoided: treating the patient too little and treating him too 
much. In all cases it is necessary to open up the burrows: to 
do this, the patient should be well soaked in hot water for 
twenty minutes, soaped thoroughly, preferably by rubbing in 
soft soap, if the skin is not too delicate, and then scrubbed 

* Schiscka, Archivf. Der?n., vol. liii. (1900), p. 3. 



1366 DISEASES OF THE SKIN. 

pretty vigorously with a hard bristle brush. The parasiticide 
should then be firmly rubbed in all over in a chronic case, or 
only in the affected parts, such as the hands and genitals, in 
a recent one. The patient should sleep with the applications 
on all night, and take an ordinary warm soap-and-water bath 
in the morning, putting on clean clothing. This cycle may be 
repeated for two or three nights in succession, but never more; 
and if done thoroughly, and the precautions against infection 
taken, success is certain, and even one such course would be 
effectual in most instances. The classical parasiticide for 
scabies is sulphur, for which there are many formulae. Simple 
sulphur ointment 5j to the 5J is generally sufficient, and the 
addition of balsam of Peru makes it less unpleasant. Sherwell 
advocates the washed flowers of sulphur, after a bath with sand 
soap. The body and .limbs are to be rubbed lightly with the 
powder — half a teaspoonful is enough. Between the sheets a 
little of the powder should be lightly sprinkled. This powder- 
ing is to be repeated every other night, and clean underlinen 
put on every other day, and in a week or ten days the cure is 
effected, if not cito, at least into ct juaindc, as no secondary 
eczema follows. 

I use in private practice, after the preliminary soaking and 
scrubbing, naphthol 15 parts, cret. prep. 10 parts, sap. mollis 
50 parts, adipis 100 parts, as recommended by Kaposi, well 
rubbed in. For infants it can be used half strength, and I omit 
the soft soap. I can speak of it in the highest praise. It is 
effectual, has no smell, and is not liable to irritate the skin, 
as sulphur does. It is, however, too expensive for public prac- 
tice. Nephritis has occurred from its overuse, but I have never 
seen any bad symptoms. Another remedy less likely to irri- 
tate the skin than sulphur is balsam of Peru, of which the 
vapor alone is said to be fatal to the acari. The balsam is 
rubbed in for twenty minutes every night, a nightshirt impreg- 
nated with the drug is worn, and in the morning an ordinary 
soap-and-water bath is taken. Hallopeau has recorded cases 
of ulceration of the skin produced by it. 

McCall Anderson prefers styrax ointment, styracis liquidi *j, 
adipis oij, or it may be prescribed with olive oil as a liniment. 
Carbolic oil 1 in 20 and a five per cent, creolin ointment 
are also used. Eudermol from 1-2 to one per cent, oint- 



SCABIES. 1367 

ment or lanolin soap has been recommended by Wolters of 
Bonn, but as it is a salicylate of nicotin, its use requires cau- 
tion, as toxic symptoms may be produced. Peruol, a synthetic 
product (benzoic acid benzyl ester), is recommended by Sachs 
and Juliusberg as being non-toxic, odorless, not staining linen, 
and a certain curative agent in thirty-three per cent, strength, 
and does not irritate the skin. The stronger sulphur applica- 
tions of Hebra and Hardy and other formulae are given among 
the animal parasiticide formulae in the Appendix. 

At University College Hospital, where there is every facility, 
sulphur baths are used. Four ounces of sulphid of potassium 
are dissolved in thirty gallons of water at a temperature of 
ioo° F. in a porcelain bath; the patient soaks in this for a 
quarter of an hour, and is then well scrubbed with a hard brush 
and allowed to soak for another quarter of an hour. While he 
is taking the bath his clothes are put in a disinfecting oven. 
Three baths are generally ordered to make sure, but one or 
two are quite enough, as a rule. The treatment never fails, 
unless the brush gets too soft to open up the burrows. When 
next the patient is seen, if he still complains of irritation, he 
has calamin lotion to soothe the skin which has been irritated 
by the long previous scratching or by the treatment. Sher- 
well's recommendation for the sheets may be used as a supple- 
mentary treatment. 

Whichever of the many applications be selected it should al- 
ways be borne in mind that the patient does not cease to itch 
immediately on the death of the acarus, and that in many per- 
sons it takes a long time before the irritated cutaneous nerves 
will settle down. Alkalin baths, and calamin lotion, and other 
soothing or antipruritic lotions should be employed, and the 
patient's mind reassured as to the disease being reallv cured. 
Sometimes some of the better classes become quite hypochon- 
driacal on the subject, and it is most difficult to persuade them 
that the acari are not alive, " crawling about them." The 
stronger, especially the sulphur applications, are often responsi- 
ble for the continuance of the itching, and it is important to 
recognize this, as of course the continuance of the parasiticide 
is only adding fuel to the fire. Three applications ought al- 
ways to be sufficient; and if the patient chance to get reinfected 
from wearing infected gloves, etc., a little naphthol ointment 



I3 68 DISEASES OF THE SKIN. 

rubbed into the fresh lesions is all that is required. Passing a 
needle through each papule insures the parasiticide reaching 
the acarus. A troublesome complication, chiefly after sulphur 
treatment, is a folliculitis of the thighs, which may go on for 
many weeks. Painting with liq. carbonis detergens, slightly 
diluted, is generally effectual. In order to prevent reinfection 
from the clothing the underclothes should be thoroughly boiled, 
while cloth clothes may be well ironed, especially the trouser 
pockets, the iron being as hot as it can be without injuring the 
clothing. It is not necessary to disinfect them by superheated 
steam, as is done in pediculosis, though that is the simplest plan 
where opportunities exist. Obviously, if there are several in 
one household affected, they must be all simultaneously treated. 

Sarcoptes Scabiei Communis. Under this head are included 
various other species of the sarcoptes, or acari, which form bur- 
rows, in which the female lives and deposits its ova. They 
affect animals, such as the horse, sheep, dog, wolf, fox, pig, and 
poultry (acarus depilis), and may sometimes be transferred to 
man. 

Although almost indistinguishable in their anatomy and 
habits, and capable of exciting a scabies eruption of ordinary 
character, except that burrows are absent, they cannot live per- 
manently in the human skin, and spontaneous recovery will 
ensue in six or eight weeks. 

In sarcoptic itch, contracted from the horse, the face and 
scalp may also be attacked; an extreme instance of this is re- 
corded by Besnier,* the whole body being also involved. The 
treatment would be the same as for ordinary scabies. 

Another species, the sarcoptes minor, lives only a few days 
on the human skin, or excites a transitory local eczema. 

In 1896 there was a veritable epidemic in Barfleur of a rare 
acarus, the glyciphagus domesticus; it did not burrow, but 
formed colonies round the hairs. 

Pascal f observed nine cases of desquamating scarlatiniform 
erythema in patches, which was traced to a minute acarus, 
" spherogyna ventricosa," which infests the larva of a moth 
which eats into barley. The patients had been engaged in sift- 
ing flour infested by these moths. 

* Ann. de Derm, et de Syp/i., vol. iii. (1892), p. 623. 
\ Ann. de Derm, et de Syph., vol. i. (1900), p. 947. 



DEMODEX FOLLICULORUM. 1369 

Layet of Bordeaux has described an acarus which irritates 
the skin, but does not burrow, and affects those who have to 
handle vanilla. 

R. Menger * of Texas records a case due, it was supposed, 
to an undescribed acarus of the genus chorioptes. The clinical 
symptoms as described are so extraordinary that the interpreta- 
tion of the case must be received with caution. 

Rasch of Copenhagen met with a lady who suffered from 
intense pruritus, with strong evidence of " scratched skin,'' 
which was traced to a parasite of fowls known as menopon 
pallidum Nitzschii. 

Dermanyssus Avium et Gallinae. Bird mites, found on 
fowls and other birds, occasionally attack man during sleep, 
and excite eczematous or other irritation of the skin, which gets 
well without treatment. 



DEMODEX FOLLICULORUM. 

Synonyms. — Acarus folliculorum ; Steatozoon, Entozoon, or 
Simonea folliculorum. 

This parasite was first discovered by Henle in 1841 in the 
ceruminous glands, and shortly afterwards by G. Simon in the 
sebaceous glands, the latter giving the first clear description 
of the animal. Megnin assigns its zoological position to the 
family Demodicides, of which it is the only genus. In the dog 
this or another species produces follicular mange,* attended 
with free suppurative folliculitis, loss of hair, emaciation, and 
even death, if not treated in time. In man the parasite is pretty 
generally distributed, being found in about one person in five 
easily, and with care in almost every one, but not in the new- 
born, and not in every sebaceous gland or comedo. It is 
easiest found in people with greasy skins by scraping the sur- 
face of the face with the back of a knife, and examining the 
scrapings in a little oil or glycerin, with a power of two or 

* Amer. Jour. Cut. and Gen.- Ur. Dis., vol. xv. (1897), p. 425. 

f Sparks, " Disease of the Skin produced by the Acarus Folliculorum," 
Med. Chir. Trans., vol. lvii. (1874), p. 239. with bibliographical notices 
and a plate. Thudichum on " Demodex Folliculorum," Med. Press and 
Circular, August 1, 1894, with plate and literature. 



1370 DISEASES OF THE SKIN. 

three hundred diameters. It may also be found by expressing 
several comedones and teasing them out in glycerin. There 
may be one or more, or even as many as a dozen, in one follicle, 
and they may be found in the sabaceous glands of the face, 
ears, and trunk. A. Kraus says they may be readily found by 
staining a film preparation with the Ziehl-Neelsen stain (vide 
Appendix). 

Although associated with seborrhea and comedones it is not 
the cause of them, and, as a rule, produces no symptoms in 
man, but occasionally it has appeared to be the cause of skin 
lesions. 

Remak records the case of a man who had suffered from an 
obstinate acne of the chin, nose, forehead, and back, and in the 
pustules with some difficulty found the demodex, but this is 
inconclusive. De Amicis met with a case of a lady, set. twenty- 
seven, who had a pigmented patch of " cafe-au-lait " color like 
tinea versicolor, which gradully spread over the lips and chin. 
There was some prominence of the follicles. Enormous num- 
bers of demodex were found in the scrapings, and the patch 
disappeared after their destruction. Dubreuilh * has met with 
a similar case. Majocchi also had seen two cases of pigmenta- 
tion with slight desquamation, apparently due to the abundant 
presence of this parasite. 

Allen of New York showed a woman at the Dermatological 
Society with lesions on the face like molluscum contagiosum, 
in which the demodex was found in a very active condition. 

Fordyce and Holder in two cases of acne rosacea found a 
large number of the demodex in the sebaceous glands. 

Anatomy. — This acarus is wormlike in form, varies much in length, 
from about | to { of a millimeter, or -^'" to \'" , and has three segments: 
cephalic, thoracic, and abdominal. The head is about £ of the whole 
body, broader posteriorly, and provided with three-jointed pedopalpi and 
mandibles, moving like scissors. From this part extends the esophagus, 
a delicate membranous tube, dilated at the end into a stomach close to the 
fourth pair of feet. The thorax is \ of the entire length, and is barrel- 
shaped, and to it four pairs of three-jointed rudimentary legs are attached^ 
The abdomen is compared to the finger of a glove, being cylindrical and 
tapering toward the end, which is rounded. It is rather more than half 
the length of the body, and has an anal cleft on the under surface close up 

* Dubreuilh, Extrait du Jour, de Medecine de Bordeaux, January 27, 
1901, refers to other cases. 



DEMODEX FOLLICULORUM. 



i37i 



to the thorax. The male and female organs of generation are well differ- 
entiated, and according to Geber it is oviparous. The larva has only six 
legs, and, like the scabies acarus, undergoes metamorphological changes 
before it is sexually matured, the abdominal part becoming longer and 
more tapering, and the cephalic part more differentiated (Fig. 105). 

Ixodes, or Wood Ticks (Nat. Ord. Acarina). Several spe- 
cies are temporarily parasitic on man. Ixodes ricinus is the 
European and temperate zone species. It bores into the skin 
with its proboscis, sucks the blood until it is gorged, swells to 




Fig. 105. — a, fully matured demodex folliculorum, dorsal view; b, under 
surface of anterior portion of body, very highly magnified (Nayler). 

the size of a large pea, falls off until it has digested its meal, 
then ascends again the pine or other tree, until a fresh victim 
passes that way, when it drops upon him and begins again. It 
produces a small wheal, and, if caught in the act, should not be 
removed forcibly, as it will then leave its proboscis in the 
wound, and give great pain; it should either be allowed to 
finish its meal in peace, and drop off spontaneously, or an essen- 
tial oil or turpentine may be painted on, which makes it with- 
draw its proboscis and kills it. 

Desnos and Laboulbene observed on the leg of a lady a 



*37 2 



DISEASES OF THE SKIN. 



growth the diameter of a pin's head, and three millimeters long, 
like a small fibroma pendulum; it increased in size for some 
days, then the pedicle ruptured and a female ixodes reduvius was 
released. If the observation is correct it is quite different to the 
usual occurrence, in which the tumor is the distended body of 
the parasite, only its head being buried, and forming what 
appears to be a pedicle. 

LEPTUS AUTUMNALIS. 

Synonyms. — Harvest bug; Mower's mite; Fr., Rouget, ven- 
dangeur; Ger., Erntmilbe, Grasmilbe. 

This is the six-legged larva of a species of the trombididse, 
" Le Trombidion soyeux," or Trombidium holosericum, accord- 
ing to Megnin,* but others say it is the trombidium autumnale. 
It is of a brick-red color, oval in shape, from 1-3 to 1-2 mm. 




Fig. 106.— Six-legged larva of the leptus autumnalis (Kiichenmeister). 

long, and 1-3 of a mm. broad, and has a fused cephalothorax, 
divided by a transverse furrow from the abdomen. The legs 
are long, six-pointed, and with two claws on the tarsus, and 
there are no discoverable sexual organs (Fig. 106). It flour- 
ishes especially in chalky districts near the sea. 

Symptoms. — The animal bores its head only into the skin, 
producing bright red papules and wheals, which itch violently, 

*"Les Acariens parasites." by P. Megnin. " Encycloped. des Aide 
Memoire." He gives there a figure of the adult eight-legged acarus as 
well as of the larva and ovum. 



PEDICULOSIS. 1373 

and become proportionately scratched, with the usual conse- 
quences. In one of my cases a general attack of impetigo 
contagiosa resulted. It usually attacks the ankles and legs 
first, but may spread to other parts of the body. It is seen 
chiefly in July and August, in people who have been in the 
fields, or among gooseberry and currant bushes, etc., and in 
severe cases may be attended by slight febrile symptoms. Duh- 
ring, on the authority of Professor Riley of St. Louis, describes 
two other species, with similar habits, as occurring in the 
Southwestern States of America, viz., the leptus Americanus, 
American harvest mite, and the leptus irritans, or irritating 
harvest mite. Geber, in Ziemssen, describes another larva which 
is common in barley, and affects the reapers and loaders; it is 
an eight-legged, yellowish-white animal, with an oval boring 
apparatus, but without sexual organs. It produces urticarial 
lesions round the mouth of the follicles, and the animals may 
be found in their neighborhood beneath the epidermis. In se- 
vere cases the urticaria goes on to more or less severe eczema- 
tous dermatitis. The treatment is by mild parasiticides, such 
as are used in scabies, naphthol or weak sulphur, or white pre- 
cipitate ointment. The soaking and scrubbing, necessary for 
scabies, are superfluous here. 



PEDICULOSIS. 

Deriv. — q)0sip> the louse. 
Synonym. — Phthiriasis. 

These terms now signify the symptoms produced directly or 
indirectly by the three kinds of lice to be presently described. 
Formerly, however, even up to the beginning of the last cen- 
tury, the name phthiriasis was given to an imaginary disease, 
in which the pediculi bred in the flesh of the victim, in enormous 
numbers, and consumed him to the very bone. 

No one, except Landois, now believes that such a disease 
ever existed. Indeed, the life-history of the pediculus abso- 
lutely negatives the possibility of a subcutaneous existence. 

This much, however, may be admitted — that certain people 
are much more attractive as hosts than others, and that some 



i 3 74 DISEASES OF THE SKIN. 

cachectic states offer favorable conditions for the rapid develop- 
ment of pediculi. In the post-mortem room, even some corpses 
develop pediculi capitis very much more abundantly than others, 
and that, too, where there was no reason to believe that they 
existed during life. Of course, in all cases, the pediculi come 
from without. While either of these terms logically refers to 
lice in general, when used without qualification, custom restricts 
the meaning to pediculi corporis. 

I. Pediculus Capitis. This parasite is extremely common 
among the children of the poor, but, unlike scabies, is rare in 
the cleanly. 

Symptoms. — The insect on the scalp excites no special lesion 
directly, but produces such intolerable itching that the patient 
is obliged to scratch vigorously, not only where the pediculus 
is at work, but all over the scalp. 

In healthy, well-nourished people, the pediculi, if in moderate 
numbers, may lead to nothing beyond this. They keep where 
the hair is thickest, viz., the occipital region; here excoriations 
from the nails soon appear, and before long, especially in the 
poorly nourished, impetigo contagiosa is produced. At first, 
discrete pustules, covered with green-black crusts, are formed, 
or, if allowed to go on, several of these coalesce into one or 
more large patches, but nearly always with some discrete 
scabbed spots beyond the main patch. Many authors describe 
this eruption as a pustular eczema, but the pus is always inocula- 
ble, and the characteristic lesions of impetigo contagiosa are 
often present on the body also. This eruption is so constant 
that a pustular eruption limited to the occipital regions is almost 
diagnostic of pediculi capitis. Where no means are adopted to 
kill them and where the hair generally is neglected, the pediculi 
extend more forward, and the nits and impetigo lesions may be 
found all over the scalp. 

These pediculi are nearly always confined strictly to the 
scalp, but have in rare instances been found on the body in 
elderly, bed-ridden subjects (Duhring), and Lydston * records 
a case of a girl of fifteen in whom they swarmed on the pubic 
hair, but were not on the scalp; also where the hair is allowed 
to hang down, similar lesions may be seen on the neck, mixed 
* Amer. Jour. Cut. and Ge7i.-Ur. Di's., vol. x. (1892), p. 399. 



PEDICULOSIS. 



1375 



with excoriations from scratching, but the impetigo pustules 
are smaller, as a rule. In cases of extreme neglect the hair gets 
matted together from the glutinous pus, and this, with the 
pediculi and other debris, scales, scabs, dirt, and fungi de- 
posited from the atmosphere, make up the condition known as 
plica polonica. 

The occipital glands, and, in severe cases, the other neighbor- 
ing glands, undergo sympathetic enlargement, are tender, in- 




Fig". 107. — Ova of pediculi capitis. 
a, natural size of hair with twenty-nine ova upon it; b, b, ova, magnified, 
showing the cement attaching the ovum to the hair shaft and the 
operculum attached, c, empty ovum, operculum fallen off. 

flamed, and may even suppurate. The mothers always state 
that the lumps came first, then the sores, and then the lice, 
this reversal of the actual order acquitting them, as they think, 
of neglect. 

Where the pediculi are only present ^n moderate numbers the 
nits are more easily seen than the pediculi. They form small 
white specks, very like a small scale, but on pulling out the hair 
the nit is seen to be situated laterally on the hair shaft, while 
a scale is generally pierced by the hair. Moreover, on passing 



1376 DISEASES OF THE SKIN. 

the fingers gently along the hair, the scale comes off, while the 
nit is glued firmly on. Commonly there is not more than one 
nit on a single hair, but where the pediculi are swarming they 
economize space and I have counted twenty-nine strung at short 
intervals on one hair. 

When the pediculi are sparse the impetigo contagiosa is often 
the only disease complained of, but scattered scabbed lesions, 
for the most part limited to the occipital region, should at once 
lead to careful examination, when the lice or their ova will cer- 
tainly be discovered. 

Etiology. — Pediculi capitis occur at all ages, but are most 
common in children. They are always conveyed from one per- 
son to another, either by direct contact, as in persons sleeping 
together, or by using the same hat, brush, comb, etc. 

Naturally pediculi are more frequent and flourish most in 
those who neither wash nor brush their hair very frequently. 

Anatomy. — The head louse is about two mm. long and one mm. broad. 
The female is much larger than the male, and exists in much greater 
numbers. The young hatch out after six days' incubation, and are fully 
developed in twelve or fourteen days more; and as each female lays from 
fifty to sixty eggs, they multiply with great rapidity. 

The head louse is smaller than the body or clothes louse; its head is 
acutely triangular, while that of the pediculus corporis is nearly oval; it 
has a broader thorax, and the margins of the abdomen are darker. The 
legs are shorter, and it is less active. 

In a male the last abdominal segment is rounded off and prominent. 
There is a valvular opening on the back, the common anal and genital 
opening. The penis, therefore, which is simple and wedge-shaped, 
protrudes on the dorsal surface. 

The female has the last abdominal segment deeply notched at the apex, 
in which the anus is placed. The vaginal aperture is on the ventral 
surface. It is clear, therefore, that the female is uppermost in copulation. 

The color of the pediculus varies according to the color of its host. On 
Europeans it is gray with blackish margins, on the Esquimaux white, on 
negroes black, on the Chinese yellowish-brown. 

Treatment. — If the patient is a child, and it is not necessary to 
preserve the hair, this should be cut off close, the crusts 
softened with oil and picked off, or the hair cut underneath them, 
and ung. hyd. ammon. freely smeared on; this kills the pediculi, 
disinfects the pus, the sores readily heal, and the nits are got 
rid of with the hair. 

Where it is necessary, as in women, to preserve the hair, the 



PEDICULOSIS. 1377 

pediculi may be killed by rubbing in ung. hyd. amnion., and the 
vitality of the nits destroyed by sponging small portions of hair 
at a time with the one in forty solution of carbolic acid; fre- 
quent combing will gradually detach the dried-up ova, or the 
cement will give way by sponging in the same way with a lotion 
of acidi acetici §ij, hyd. perchlor. gr. 3, aquam ad § vn J- Where 
the disagreeable smell is not a bar to its use, soaking the whole 
head freely with petroleum, such as is used for lamps, is imme- 
diately destructive to the lice, loosens the nits, and the impetigo 
contagiosa can then be treated with the ung. hyd. amnion, dil. 
It is said that lice are quickly destroyed by infusion of quassia, 




Fig. 108. — Male pediculus capitis, showing its system of tracheae and its 
respiratory stigmata (Kiichenmeister). 

to which a little glycerin of borax has been added. It has the 
advantage of being cleanly and free from smell, but it would 
not detach the nits. 

II. Pediculus Corporis. Synonyms. — Pediculus vestimenti; 
phthiriasis. 

Symptoms. — This parasite is a denizen of the clothes, in which 
it carries on all its life processes,* except feeding. Like most 
parasites it thrives most where the nutrition of its host is at 
a low ebb. It is, therefore, almost restricted to the aged and 
the dirty, the half-starved and cachectic, and it is only seen in 
the young when they are very neglected, or in very close con- 
tact with older victims. 

The lesions produced by its presence are mostly secondary 
and due to violent scratching, which the operations of the insect 

* Jamieson's observation that the ova may sometimes be found on the 
lanugo hairs does not invalidate the general truth of this statement. 

87 



1378 DISEASES OF THE SKIN. 

induce. The only direct lesion is a minute hemorrhagic speck, 
only just perceptible to the eye, and not at all to the touch. 

Its production, according to Tilbury Fox, depends upon the 
mode of feeding. Schjodte describes this pediculus as follows: 
" It possesses no mandibles or other means of biting, but only 
a kind of sucking apparatus, consisting of a membranous tube, 
which can be protruded at pleasure. When the pediculus is 
about to feed it inserts its labium into a sweat pore, and pro- 
trudes the lip. This lip is surrounded by a collar of hooks, 
which, though straight when at rest, become curved outwards 
when the lip is protruded, and thus afford a hold on the skin. 
The tube is now inserted, and the blood sucked up; and when 
the meal is concluded the blood wells up into the orifice, and 
forms at first a pin's-point-sized, bright red speck, in a minute 
depression in the center of a small, transitory wheal, and when 
the wheal, which itches violently, subsides, the speck of dry 
blood alone is left." I am, however, inclined to think it is only 
the excrement of the animal; but, however that may be, this 
" hemorrhagic speck " is as distinctive as the burrow of the 
acarus is for scabies; but, inasmuch as it requires very careful 
looking for, the secondary lesions attract most attention. One 
of these may be easily mistaken for the characteristic speck. 
It is a small blood crust produced by the decapitation by the 
nails, of a slightly hyperemic follicle. It is, however, not only 
larger than the " speck," but the nail, when passed over it, 
catches, while the hemorrhagic speck is imperceptible. The 
secondary lesions are all those described under the " scratched 
skin " (p. 42) ; excoriations, wheals in parallel lines and spots, 
ecthymatous sores, and ultimately dirty brownish, in rare in- 
stances almost black pigmentation, with thickened, leathery 
skin. In themselves there is nothing distinctive, their diag- 
nostic importance depending upon their localization. 

The favorite habitat of the pediculi is just underneath the 
neckband of the underclothing. Here they first establish them- 
selves, and are always most abundant, and it is at the nucha 
and shoulders, therefore, that their ravages are greatest, and 
the scratching most vehement. So much is this the case that 
extensive scratchmarks on the nucha and shoulders, in an 
elderly person, are practically diagnostic of pediculi corporis; 
when to these are added the hemorrhagic specks, the discovery 



PEDICULOSIS. 



1 379 



of the pediculi themselves or their ova on the clothes is fortu- 
nately of secondary importance, for too often, if the patient is 
lucky enough to possess a change of linen, he pays the doctor 
the compliment of putting it on just before his visit, and of 
course no pediculi are then to be found. Only in extreme 
cases, or at their mealtimes, are they to be found on the body 
itself; and where they are so abundant, especially if in a young 
person, a pyrexia of several degrees, even as high as 106.4 , 
has been observed. This Jamieson thought was reflex from the 
cutaneous irritation; but Payne, with more probability, thinks 
it may be due to some poison inserted by the insect analogous 
to that of the mosquito, bug, etc. In cases of some duration 
in dirty people the scratch-marks are to be seen all over the 
trunk, except between the shoulders, which are not easily 
reached; on the front and inside the thighs, but not much below 
the knees; on the arms, but not much below the elbows, while 
the hands and wrists are always free. The thickened, leathery, 
and much-pigmented skin is always a sign of chronicity, and 
being common in tramps, is sometimes called " vagabond's dis- 
ease." Hebra regards this as the pityriasis nigra of Willan, 
and gives a plate of it in his atlas,* where the whole skin was 
of a deep bronze hue. 

This melanodermia is sometimes out of proportion to the 
actual scratching, especially in chronic alcoholic and other 
cachexias, and is not confined to the infested regions. 
Thibierge has found it on the buccal mucous membrane, and 
suggests that the lesions of scratching are transformed into 
pigment which gets into the circulation. Boudon's suggestion 
that it is the direct product of the parasite inoculating an irritant 
saliva lacks proof and probability. 

The subjective symptoms are itching, burning, and formica- 
tion, very intense, and always worse at night, not confined to the 
regions of the insect's operations, but reflexly felt anywhere 
and everywhere. 

Etiology. — As already stated, phthiriasis affects the old rather 
than the young, the badly nourished and cachectic rather than 
the healthy and well-fed, the poor rather than the rich, dirt, 

*Lief v., Plate XI., and Kaposi's Hand Atlas, Plate CCXXI. Alibert 
in his quarto edition of 1832, p. 526, gives a plate in which the skin was 
quite black where the pediculi were most numerous. Vide note, p. 664. 



1380 DISEASES OF THE SKIN. 

neglect of ablutions, and alcoholism being the other chief favor- 
ing conditions. 

However suitable the subject the disease is only acquired by 
the transference of the pediculi or their ova from another indi- 
vidual, spontaneous breeding being only a popular fiction. On 
the other hand, in young and vigorous subjects, even if exposed 
to infection, the lice will often fail to flourish, and even after 
infection in a young but half-starved patient, with cleanliness 
and good feeding alone, they will often die off. Clearly, there- 
fore, unlike the acarus scabiei, the pediculus corporis has its 
preferences, probably some odor in the favored person com- 
mending itself to the parasite. Indeed, I know of an instance 
in which four young medical men placed a pediculus in the 





Fig. 109.— Female pediculus vesti- Fig. no.— The pediculus pubis, or 
menti (Kiichenmeister). crab louse (Schmarda). 

middle of a small table, round which they stood, and the pedic- 
ulus invariably went towards the same man, though they re- 
peatedly changed their positions. 

Kaposi, however, is of opinion that it is only because the 
well-nourished and the better classes are seldom exposed that 
they are seldom attacked; but this cannot be the whole truth, 
as pediculi corporis are seldom seen, even in dirty children. 
According to Cobbold, the pediculus of the cachectic is a sep- 
arate species — P. tabescentium, or distemper louse. 

Anatomy.— The body louse is larger than the head louse, which it 
otherwise closely resembles. The length is two to three mm. (three- 
quarters to two lines), and it is half that in breadth. The head is more 



PEDICULOSIS. 138 1 

oval and elongated than that of the head louse; the antennae are longer, 
the thorax distinctly segmented, the legs more developed, with larger 
claws, and it is, therefore, more active. The color is dirty white, with 
black margins. In other respects it is like the head louse, the larger size 
being the most conspicuous difference (Fig. 109). 

Diagnosis. — The diagnosis lies in the conspicuous evidence of 
scratching on the shoulders and nucha, especially in an elderly 
person, in its absence from the hands and wrists, and in the 
presence of the characteristic " hemorrhagic specks." Search 
in the folds of the clothing, especially about the neck, will result 
in the discovery of the pediculi and their ova, unless the linen 
has been very recently changed. In the younger patients, ova 
may sometimes be found on the lanugo hairs. However clean 
the patient, search for the parasite should always be made if 
pruritus is severe without other obvious cause. 

Treatment. — The disease is always readily curable, if it be 
borne in mind that the pediculi live in the clothes, and 
to them, therefore, the principal treatment should be directed. 
Where facilities exist the clothes should be placed for some 
hours in a disinfecting oven, of at least 212 F. Failing the 
opportunity of this, repeated boiling will be effectual for the 
linen. For the patient free ablutions with soap and w T ater and 
alkaline baths to soothe the irritable skin should be employed. 
The ung. staphisagrise, or petroleum lamp oil, freely rubbed in, 
kills any chance pediculi or ova that may be on the skin, or on 
any part of the clothing in contact with the skin. Care must 
be taken against reinfection from the bedding, etc., which 
should be treated like the body clothes. In marasmic sub- 
jects, suitable measures in the way of feeding, cod-liver oil, 
and the removal, if possible, of the cause of emaciation, are 
valuable adjuncts. 

Jamieson recommends that a small lump of roll sulphur 
should be wrapped up in a porous bag and worn constantly next 
the skin; sulphurous acid is imperceptibly given off. 

III. Pediculus pubis. Synonyms. — Phthirius pubis; Crab 
louse; Fr., Morpion. 

Symptoms. — This species resembles the pediculus capitis in its 
habits, but is much less common. The chief haunt of these 
insects is the pubic hair, from which they may spread up to the 



13S2 DISEASES OF THE SKIN. 

hair on the raphe of the abdomen, to the shaggy hair of the 
thorax, and thence to the axillae and limbs. In very filthy peo- 
ple and in children, it may also be seen on the eyebrows * and 
lashes, when the minute nits on the hair and the " hemorrhagic 
specks " on the adjoining skin are the most obvious feature. 
At the same time they lie so flat on the eyelids that only careful 
examination with a lens will reveal their presence. The whis- 
kers and beard may also be sometimes attacked, and it has 
very rarely been found on the head. In a case by J. Heisler 
from Rona's " Poliklinik," a child of fourteen months, who 
had slept with a servant-maid, had them not only on the lids 
and lashes, but all over the scalp, nits also being abundant there. 
Trouessart met with a case, aet. five months, contracted under 
precisely similar circumstances. 

Grindon f met with a group of cases, five children and the 
father and mother; the parasite was confined to the margin of 
the hairy scalp, not encroaching on the scalp for more than 
an inch. They were also on the youngest child all over the 
body, clinging to the lanugo hairs. White of Boston and 
Jamieson also mention cases. 

Being much more stationary, of small size, of yellowish-brown 
color, and lying flat on the skin, it is easily overlooked. Cling- 
ing usually to a couple of hairs, it digs deeply into the orifice 
of a hair follicle, and usually excites great and persistent irrita- 
tion, though in some cases the irritation is very trifling. 
Scratched-topped papules seated at the follicles are the most 
commonly excited lesions, but if the pediculi are left to flourish 
more severe eczematous inflammation is excited, and may 
spread beyond the site of its irritation. Pyrexia has been ob- 
served in connection with this species also (Payne). 

Besides the pediculi and their minute gray-colored nits, which 
are attached to the hair close to the skin, Morrison, in 1868, 
showed that finger-nail-sized, steel-gray spots of pigmentation 
(maculae caeruleae, taches ombrees) are sometimes observed 
deep in the epidermis of the affected areas; and Duguet, in 

* Cobbold considers that the lice that affect this position are a distinct 
species, which he calls the P. palpebrarum. 

f " The Migrations of Pediculi," The Medical Fortnightly, St. Louis. 
Chicago, March 15, 1893, with numerous references to cases of pediculi 
n unusual positions. 



PEDICULOSIS. 1383 

1880, 1882, showed that this pigment was contained in the 
thorax of the animal opposite the anterior pair of legs, where 
there are known to be two pairs of salivary glands, and it is 
probable that the secretion is conveyed into the tissues through 
the haustellum. The blue spots are more marked in persons 
with clear, white, transparent skins, and in the months of 
February, March, and April. The blue spots are, therefore, 
mere stains of the epidermis, and disappear in a few days after 
the destruction of the pediculi. Jamieson thinks that the stains 
have some anesthetic effect, as far as itching is concerned, 
though not for the other sensory phenomena. Oppenheim * has 
observed a green coloring matter in pediculi pubis, especially in 
impregnated females, while it was absent in the young lice. 

Etiology. — This variety is more commonly seen among the 
well-to-do than the other kinds, being most frequently com- 
municated during impure intercourse. Of course it may be also 
derived from the bedding, clothes, etc. 

Anatomy. — The pediculus pubis (Fig. no) is much broader and flatter 
in proportion than the other pediculi. The female is about one and a 
half to two mm. long and three-quarters of that broad. The male is 
about half the size of the female, and the terminal segment of the abdo- 
men is rounded, while in the female it is notched. The head is rounded, 
provided with five pointed antennse and two small, prominent eyes be- 
hind them. It has a neck, by which it is attached to the sulcus of the 
heart-shaped body, the broad, flat thorax being merged into the abdomen, 
and carrying anteriorly a slender pair of legs, which are used for walk- 
ing, and terminate in a straight claw; while the two posterior pairs of 
legs are stronger, and used for clinging and climbing, and are accord- 
ingly provided with strongly curved claws, and, with the tarsus, make 
three-quarters of a circle. The ova are ten or fifteen in number, hatch 
out in a week, and the young are sexually mature in two weeks. 

Diagnosis. — The diagnosis can present no difficulty if the pos- 
sibility of their existence be borne in mind in every case of 
pruritus of the pubes and other regions liable to their attack. 
At the same time they require a close investigation, as they 
are very small objects, being almost immobile and lying close 
to the surface, they do not look like live animals. A common 
source of error is that the secondary eczema occupies all the 
attention until the fact of the irritation being out of proportion 
to the degree of eczema induces closer investigation. 
*Archiv f. Derm. u. Syph., vol. lvii. p. 235. 



1384 DISEASES OF THE SKIN, 

Treatment. — Naphthol ointment, as recommended in scabies^ 
should be rubbed in, or hyd. oleat. five per cent. 5vj, ether sulph. 
oij is a good application, and kills the nits; or Peruvian balsam 
and vaselin or lard, in equal parts; or they may be subjected to 
the vapor of chloroform; or the part may be freely dabbed 
with a lotion of hyd. perchlor. 1 in 250, and the nits destroyed 
with carbolic lotion 1 in 40. The classical treatment of two 
good rubbings of the ung. hydrargyri is effectual, but not free 
from the danger of exciting a dermatitis of its own. Calamin 
lotion should be applied freely after the animals and their ova 
are killed, in order to allay the irritation, which does not sub- 
side at once; and the patient's mind should be tranquilized by 
explaining this, or he is apt to fancy himself uncured, and resort 
to violent and quack remedies. The various lotions for nits 
already described for pediculi capitis find a place here also. It 
is better not to cut the hair on the pubes, as the pressure of 
the clothes on the ends of the growing hair produces intolera- 
ble irritation, until the hair has grown long enough to curl. 

Pediculi ciliorum are best treated by picking off the living 
lice with forceps, rubbing on diluted nitrate of mercury oint- 
ments, and sponging the eyelashes with carbolic lotion 1 in 40 
to kill the nits. 



PULEX PENETRANS. 

Synonyms. — Rhynchoprion penetrans; Nigua; Chigoe; Jigger; 
and many other local names. 

This parasite is indigenous to tropical America, between 
23 N. and 28 S., and in 1872 was imported into Africa, and 
spread widely over the Gaboon and Congo coast. It has also 
been met with in Madagascar and China. It only survives for 
a short time (a few months) when imported into temperate 
climates. Dry sandy soil, the dirty huts of negroes and Indians, 
piggeries, cattle-sheds, and poultry-pens are its chief quarters. 
The animal is like a common flea, but smaller, with a proboscis 
as long as its body, and has a deeper abdomen. 

The impregnated female alone bores obliquely into the skin, 
most commonly under or beside the toe-nails, between the toes, 
or the less common positions are, parts of the foot other than 



PULEX PENETRANS. 1385 

the toes, the arms, scrotum, knee, upper extremity, and face, 
burying herself all but the two last segments, which plug the 
orifice of entrace and do not partake of the enlargement of 
pregnancy. She remains until the maturation and extrusion of 
the eggs, which distend the abdomen into a sac as large as a 
small pea. 

A thirteen-ringed larva hatches out a few days after the ova 
are deposited on the ground, and some days later incloses 
itself in a cocoon, from which it emerges in eight to ten days 
as the perfect imago, taking probably about the same time for 
her life-history as the common flea, viz., rather less than a 
month. 

Her subcutaneous sojourn excites painful inflammation, 
swelling into a pea-sized tumor, suppuration, and ulceration, 
tending to expulsion of the parasite, but not until she has ful- 
filled her destiny and has discharged her ova. The resulting 
ulcer may from secondary microbic infection be the seat of 
extensive ulceration or gangrene, and even tetanus may super- 
vene. There is usually only one or two chigoes in a foot, but 
there may be hundreds producing a honeycomb of cicatricial 
pits (Manson) ; Decle speaks of 280 from one person. 

The treatment consists in picking out the chigoe with a blunt 
needle, taking care not to rupture the abdomen; anointing the 
foot with essential oils, chloroform, turpentine, or carbolized 
oil, which kills the insect and prevents further attacks. Abscess 
cavities should be washed out with disinfecting solutions — cor- 
rosive sublimate one in two thousand, or carbolic acid one in 
forty. 

Cleanliness, washing the floors with carbolic acid, and always 
wearing shoes are the best prophylactics. 

Pulex Irritans. The common flea is only too well known. 
It produces a red spot, seldom so wheal-like or large as that 
of the bug, with a central puncture, which, when recent, will 
distinguish it from erythematous eruptions due to internal 
causes, but in a short time, especially in cachectic subjects, it 
becomes petechial, and, if associated with fever from some 
other cause, may give some trouble in diagnosis from typhus, 
measles, etc. The general dirtiness of the patient, and the more 
recent bites, will give a clew to the cause. 



1 3 86 DISEASES OF THE SKIN. 

The human flea may be transferred to the dog, and that of 
the dog to a man, but it does not live long upon him. Berg 
records a case of a filthy old woman with psoriasis, in which the 
larvae of the common flea were flourishing among the scales 
and crusts of her disease. A rise of temperature has been 
known to occur from extensive flea-bites. 



Cimex Lectularius, Acanthia lectularia, or common bed bug. 
This animal, with its repulsive smell, is too well known to need 
description. It comes only on the human body to feed, punc- 
turing the skin, injecting an irritating fluid to increase the 
hyperemia, and sucking its victim's blood. It produces a wheal, 
a raised red spot, with a whitish center and a central puncture, 
and on the subsidence of the swelling there remains a purpuric 
spot, which follows the usual course of petechiae. A formidable 
species, the Conorhinus sanguisugus, or " big bed bug," excites 
severe inflammation, and is said by Riley of St. Louis to be 
found in beds in Illinois and Ohio. 

Treatment. — Toilet vinegar, carbolic acid lotions, weak liquor 
ammoniae, corrosive sublimate one in five hundred, or Goulard 
water sponged on freely, or the lotions recommended for 
urticaria, give most relief. 

Culex Pipiens and other Gnats and Mosquitoes of various 
species, all over the world, attack man and produce a wheal, 
and in hot climates they are a real pest, and great precautions 
have to be taken to prevent their access at night. Species of 
tabanidae and simulium also excite wheals in different localities. 
Weak liquor ammoniae or sal-volatile, and the other remedies 
mentioned under bug-bites, give relief to the intolerable itch- 
ing. Rubbing the part with soap, and allowing a stream of 
cold water to run on it, is said to give immediate relief. Car- 
bolic oil rubbed on is another good remedy. The tsetse fly, so 
fatal to beasts of burden in Central Africa, produces wheals only 
in man. Sponging the surface with infusion of quassia is a 
good prophylactic against mosquito-bites and the importance 
of prevention is very great now that they are known to be the 
carriers and circulators of so many diseases, such as yellow 
fever, malaria, filaria, etc. 



PULEX PENETRANS. 1387 

CEstrus, Gadbreeze, or Bot-fly.* The term " myiasis" or 
dermato-myiasis has been proposed for the attacks of dipterous 
larvae on the human subject, but the cases are too rare to re- 
quire a special name. Cases of the presence of dipterous larvae 
of several species of cestridae in the skin have been reported 
from time to time by various writers in Europe, of whom 
Walter Smith, McCalman, Walker of Shetland, and Dubreuilh 
may be specially mentioned. In Shetland it is said to be com- 
mon, and always in women. It is often met with in Africa, 
especially in Senegal, and in Central and South America, where 
it is known as " ver macaque." They are all for the most part 
parasites of herbivorous animals, dogs, etc., and are only oc- 
casional visitants to man. Humboldt's oestrus hominis is now 
known to have no existence. 

The ova or larvae are deposited under the skin by means of 
the stinging apparatus, and set up either furuncular inflamma- 
tion with a central aperture, through which the larvae may be 
pressed, together with a sanious fluid, or they burrow under the 
skin, forming irregular serpiginous lines of wheals, which 
Walker compares to that produced by an inflamed lymphatic, 
but it is of a purplish color; at the end of this line suppuration 
occurs before the larva escapes. Carbolic acid (1 in 40) should 
be injected into the cavity after evacuating the larva. 

The gastrophilus larva is separately described below. Other 
dipterous larvae invade the skin only where there is a previous 
breach of surface, such as the sarcophila Wohlfarti (Europe), 
the lucilia hominivorax, and macellaria (America and Asia) ; 
they produce severe ravages in a short time, inducing gangrene 



* Lite rat tire. — Smith reports an interesting case of dipterous larvae in 
the skin in Report of Inter. Med. Cong., London, 1881, with partial bibli- 
ography and the substance of McCalman's case. Matas, in reporting a 
case from Honduras in which red furuncular swellings were produced, 
says there are three species which attack man — the hypoderma bovis, a 
species of trypoderma or cuterebra, and dermatobia noxialis; his case 
was due to the last species. W. Dubreuilh, " Les Dipteres Cuticoles 
chez l'Homme, Archives de Medecine Experimental, No. 2, March, 
1894, a comprehensive account with valuable references. Abraham gives 
a good historical and bibliographical account of the subject, Trans. 
Derm. Soc. G. B. and I., vol. iii. (1897), p. 62. His criticism of' my name, 
"larva migrans," is beside the mark, as it is obvious that it was proposed 
for the larva, and not for the disease. 



1388 DISEASES OF THE SKIN. 

of the skin, destroying fat muscles and vessels, and endanger 
life. 

Larva Migrans of Gastrophilus.* This lesion, produced by 
the above-named larva, was first described by Robert Lee, as 
a " creeping eruption " from two cases (1875 an d 1884), then 
by myself (1892), and Neumann and Rille of Vienna, 1896. It 
appears, however, to be fairly common in Southeast Russia, 
near the Volga, where it is popularly called Wolossatik (Woloss, 
hair), two Russian observers, Sokoloff and Samson-Him- 
melstjerna, seeing two or three cases a year in that district. 
A case has also been observed in Bulgaria. 

I am informed that in children in Arabia it is very common, 
and that mothers burn the part with a hot wire. 

The two Russian observers have found the larvae, which 
others have failed to do. 

They identify it as the larva of a dipterous insect, order 
cestridae of the genus gastrophilus, species undetermined; but if 
SokolofFs observation that he found black empty nits on the 
hair in the neighborhood of the track is correct, it would sug- 
gest one of two species, hemorrhoidalis or pecorum, as only 
these two have black nits. The larva is spindle-shaped, seg- 
mented, and from one to one and a half millimeters long. 

How the larva gets into the skin is unknown; the mother of 
my case said that the child was found with half a slug in her 
hand, as if it had been bitten off. Several cases have commenced 
in the buttock and have been attributed to the closet seat, but 
the more probable explanation is that the insect took advantage 
of the exposure of the buttocks to deposit its ova in the skin 
of that part. The lesion produced is a narrow red line a sixth 
to an eighth of an inch broad, only just perceptibly raised. 
This line travels over the surface at the rate of an inch or more 
a day, an inch being the usual distance, performing all kinds 

* Literature.— Author's Atlas, Plate XCIII., Figs. 2 and 3, with full 
account of the case which was sent to me by Dr. Travers Smith. Clin. 
Soc. Trans., vol. viii. (1875), p. 44, with report; and vol. xvii. p. 75. 
Neumann, Archiv f. Derm. u. Sypk., vol. xxxiv.. Heft 1 (1896), p. 905; 
abs. Brit. Jour. Derm., vol. viii. p. 145, of Russian papers. Samson- 
Himmelstjerna, " Ein Hautmaulwurf," with plate of case and woodcut 
of gastrophilus larva. Short abs. Amer. Jour. Cut. and Gen. -Ur. Dis., 
vol. xvi. (1898), p. 297. 



CRAW-CRAW. 



1389 



of curves and gyrations, though sometimes it goes straight, 
once, in my case, for seven inches in a day. The red line fades 
at the passive end in a few days, while the larva itself is from 
a. quarter to an inch or more beyond the active end, where there 
is some itching and burning by which some adults can locate 
the larva. The larva may travel more or less actively for 
months; in my own case it was on the march for two and a 
quarter years, when it was apparently killed by a suppuration 
in the neighborhood of the track, but it is never the exciting 
cause of a suppuration. It may limit itself to a small area, e. g., 
one cheek (Matschinsky), or travel all over the thigh and 
trunk, as in my case, sometimes rapidly. 

Treatment. — Subcutaneous injections of carbolic and iodin 



Fig. in. — Larva of gastrophilus. 

solutions failed in my case, only stimulating the larva to in- 
creased exertions; external applications had the same effect. 
Excision of a portion of skin (half an inch beyond the red line) 
is the only plan which has been successful. Samson-Him- 
melstjerna says the parasite can be located as a dark point by 
pressing the blood out of the skin with a lens; its removal 
would then be easy. 



CRAW-CRAW. 



This is a disease of the west coast of Africa, occurring 
chiefly in negroes. Conflicting accounts are given by different 
reporters, and further observations are needed before a definite 
conclusion can be arrived at. 

Probably the term craw-craw is used rather loosely in Africa. 
I had a patient, an officer from the west coast of Africa, who 



1390 DISEASES OF THE SKIN. 

said he was told there that he had craw-craw, but what I saw 
was evidently tinea cruris. C. S. Grant, who practiced in West 
Africa, says that it is a kind of scabies, and is curable by itch 
treatment; others deny its curability by sulphur. 

According to O'Neill * it is an eruption with papules, vesi- 
cles, and pustules, attended with violent itching, and looking 
like old scabies, but the eruption and itching decline if the 
patient goes to a cooler climate, and return in the hot, moist 
climate of the west coast. 

If the top of a papule is shaved off, moistened with water, 
and placed under the microscope, a filarial organism, something 
like the filaria nocturna, may be found, but it has two dis- 
tinctive black marks near the cephalic end, and is also shorter 
and broader (P. Manson). 

Manson also draws attention to a possible fallacy, as in that 
part of Africa filaria perstans affects half the population, and 
might therefore be present without being the cause of the mal- 
ady in question. Still, as craw-craw and filaria perstans have 
a similar geographical distribution, they may be etiologically 
related. Emily,* who has proved himself to be a good ob- 
server, says it is well known on the French Congo and the 
Upper Ubanghi district. It has a highly characteristic course 
and appearance. 

" Commencing as a small reddish-brown macula, situated 
usually on the lower extremities, but also on the dorsal aspect 
of the hands and elsewhere, the disease from the first is attended 
by an intolerable itching, which forces the sufferer to scratch 
himself violently. A craw-craw ulcer, when fully established, 
is encircled by a zone of inflamed skin of the color of wine lees, 
and may attain the dimensions of a five-franc piece. It consists 
in an excavation with nearly perpendicular sides, and a granu- 
lating bottom whence thickish pus exudes. When exposed to 
the air this secretion hardens, covering the surface of the 
sore with a dense, impermeable pellicle, beneath which the 
pathogenic agents, whether specific or otherwise, doubtless pul- 
lulate freely. Craw-craw has been ascribed to the gonococcus. 

* Lancet, vol. i. (1895), p. 265, with illustration of the worm. 

f Archives de Medecine Navale, 1899; full account in Lancet, March 15, 
1899, p. 782, from which the following description is quoted. Emily's 
paper was sent from Fashoda on December 8, 1898. 



CRAW-CRAW. 



39 ] 



The ulcers are invariably multiple and may occur all over the 
body. Dr. Spire of Ubanghi has met with them on the penis, 
where they simulated chancres, the resemblance being accentu- 
ated by inguinal adenopathy." 

Nicholls, in his report on yaws in 1893, describes " coolie 
itch " as he saw it in St. Lucia, and it resembled Emily's account 
of craw-craw in many respects, although derived from East 
Indian emigrants; while Numa Rat * in St. Kitt's described 
quite a different affection as " coolie itch," the papules being 
dry, and there being no vesicles, pustules, or ulceration. 

According to Manson, the case reported by Silva Aranjo in 
Brazil as a case of craw-craw with chyluria and elephantiasis 
Arabum, in which he found embryo filaria, and one dead mature 
one in the urine, but none in the skin, is really a case of filaria 
nocturna, which is also well known as a cause of lymph abscess, 
tropical elephantiasis Arabum, and lymph scrotum. 

Nielly of Brest in 1882 observed the case of a boy, set. four- 
teen, who had never left France, with symptoms like craw-craw, 
and he found nematodes in the papules in all stages of develop- 
ment, some of them sexually mature females, very like the 
filaria described by O'Neill. They had two peculiar markings 
at the cephalic end, a well-defined alimentary canal, but rudi- 
mentary genitals. At one time it was associated with a nema- 
tode embryo. Probably, writes Manson, the skin parasite was 
an advanced form of the embryo of the blood, and both were 
the offspring of a mature worm somewhere in the tissues, the 
rhabditis Nielly. Nielly thought it belonged to a species of 
leptodera of the family of the anguillulidse, a view with which 
Geber agrees, both for this and O'Neill's case. The natives 
consider that craw-craw is contagious, and that it has an in- 
cubation period of three days; but if it is a filarial disease, as 
above described, it could not, says Manson, be contagious, and 
must have a much longer incubation. 

It is evident that there is a good deal of confusion on the 
subject. As far as I can judge Emily's account seems to me 
most likely to represent the real affection, but even there the 
pathology is left obscure, and perhaps Brault's conclusion is 
the right one. After analyzing the descriptions of previous 
authors, he says that it will ultimately be dismembered by fur- 
* Brit. Jour. Derm., vol. viii. (1896), p. 201, with photograph. 



1392 DISEASES OF THE SKIN, 

ther investigation, and cease to be considered a special morbid 
entity. 

Treatment. — Hitherto relapses have taken place even after 
prolonged treatment and apparent cure. Emily, however, be- 
lieves he has found a cure in boric acid. 

The skin round the ulcer must first be made aseptic, remov- 
ing hair and washing with soap, followed by corrosive sublimate 
solution. The ulcer itself is also cleansed with the perchlorid 
and boiled tepid water, wiping the base firmly with wet lint 
until all pus is removed. 

Pure boric acid is then freely applied, followed by boracited 
vaselin and antiseptic bandaging; the pain of the above pro- 
cedure soon subsides. After five or six days the dressing is 
removed and the ulcer will be healed. 



DRACUNCULUS MEDINENSIS.* 

Synonyms. — Filaria medinensis; Guinea-worm; Dracontiasis. 
This is the proper name for the disease, but it is rarely 
employed. 

Definition. — A nematode worm of the genus dracunculus, 
which attains to maturity in the human body, and forms a sub- 
cutaneous abscesslike tumor, preliminary to its exit. 

The disease is endemic in Arabia Petraea; the borders of the 
Persian Gulf and Caspian Sea, Bokhara, where it is universal; 
the East Indies, especially Bombay and Scinde, and the banks 
of the Ganges; in Upper Egypt, Nubia, Abyssinia, the coast of 
Guinea and the Gold Coast, and Mauritius; and occasionally 
in some of the West Indian islands and in Brazil. 

Of all these places, on the West Coast of Africa and the 
Deccan it is most prevalent, affecting almost the whole popula- 
tion at some seasons of the year. It is only seen in Europe 
in those who have recently lived in its usual haunts. Domestic 
animals occasionally contract the disease, and it has also been 
observed in the dog. 

* Literature. — " Srcience and Practice of Medicine," by Aitkin, seventh 
edition (Griffin, London), " Parasites.'' byCobbold (Churchill, 1870), con- 
tains the bibliography up to date. " Guinea-Worm and Dracunculus," by 
J. A. B. Horton (Churchill, 1868). Manson's "Tropical Diseases," 1900. 



DRACUNCULUS MEDINENSIS. 1393 

Symptoms. — The worm gives rise to no trouble until fully 
developed, when it can be felt under the skin like a coil of soft 
string. It frequently migrates to a considerable distance from 
the point where it was first observed before it reaches its point 
of exit, and may keep up its travels for months. When about 
to escape, in the slighter cases, a sharply circumscribed pea- 
sized vesicle is formed, and may increase to the size of a filbert; 
its formation is preceded and accompanied by a feeling of ten- 
sion and itching. When rupture occurs, either from scratching, 
poulticing, or puncture, a serous fluid escapes, which is clear 
if the worm is entire, but turbid if the young have escaped; a 
shallow ulcer or excoriation is exposed, corresponding to the 
size of the vesicle. In the center of this is a large pin-hole 
through which the white head of the worm may or may not be 
extruded. If not, Manson's procedure is as follows, in nearly 
his own words: A gentle stream of cold water from a sponge is 
allowed to fall on the opening, when a droplet of fluid, at first 
clear, then milky, comes up through the hole and spreads over 
the ulcer; or a pellucid tube, one-sixteenth of an inch in 
diameter, the prolapsed uterus, protrudes for about an inch, 
then suddenly fills with an opaque whitish material, ruptures, 
and collapses, discharging myriads of coiled-up sluggish em- 
bryos which straighten out in water and are one-thirtieth of an 
inch long and very active. Even without the stimulus of a cold 
douche, the head of the parent worm is usually gradually ex- 
truded, either at once or only after some delay. If not ex- 
truded at once, sometimes the wound closes, and another tumor 
forms in the neighborhood, but in a properly managed case, 
the removal is effected in from three to ten days, and the ulcer 
soon heals. In more severe cases violent inflammation may 
occur along the whole worm track, and there is then pain, red- 
ness, and swelling, followed by a copious purulent or ichorous 
discharge, hectic fever, and perhaps delirium. 

This inflammation is liable to kill the worm and lead to its 
breaking during extraction — a very serious accident, which 
may result in crippling, gangrene, and even death from exhaus- 
tion, or from tetanus, the abscess bursting into the abdominal 
cavity, etc. These serious consequences are generally consid- 
ered to be due to the escape of the embryos into the tissues, 
where they were once found by Bottcher. In more fortunate 
88 



i 3 94 DISEASES OF THE SKIN. 

cases, when the live worm is broken, it may be discharged at a 
later period by the formation of a fresh tumor. The point of 
exit is, in two-thirds of the cases, in the foot, especially in the 
heel; in about a fourth of the remainder, the exit is on the leg 
and thighs, and in exceptional cases it has occurred on the 
scrotum, hands, trunk, neck, head, nose, and orbit; in short, the 
worm has been found almost everywhere, except in the brain 
and eye. As a rule, there is only one worm, but sometimes two, 
and as many as fifty have been recorded (A. Farre), and Dr. 
Mircus of Lissa recorded a fatal case, where the whole body 
and skin were a network of guinea-worms. When the worm 
dies prematurely, before the skin is pierced, it may either set up 
an abscess or become cretified. 

Pathology. — The female worm, to which this disease is due,, 
has a uniformly cylindrical shape, one-tenth of an inch in 
diameter, and is usually from twenty-five to thirty inches long,, 
though extremes of one foot and six feet * have been recorded, 
the African being larger than the Indian worm. The tail is 
pointed and curved into a hook, the head slightly convex, with 
a central mouth, surrounded by four small, equal papillae and 
two larger. It is viviparous, inclosing an enormous number of 
embryos, and it reaches its destination in the following way, 
as discovered by Fedschenko of Turkestan. The embryos, 
which have escaped from man into water, penetrate the bodies 
of a minute crustacean of the genus cyclops (species quad- 
ricornis), where they undergo full larval development in five 
weeks in hot and nine or ten in colder climates. When the 
cyclops host is swallowed in the drinking water, or accidentally 
in bathing, the larvae escape, undergo sexual development and 
impregnation in the human interior at an early stage of their 
existence, and the female then sets out on her migrations 
through the tissues, the male, which has never been discovered, 
dying, and being absorbed or cast out in the feces. 

The impregnated female very soon makes her way into the 
connective tissue between the muscles, and grows quickly to 
some size, pains in the muscles sometimes testifying to her 
presence; but it is nine to twelve months from the date of her 

* Ewart measured forty worms and found the extremes twelve and' 
forty inches. It has been suggested that the worms of extreme length 
are really cases where two worms have been measured as one. 



DRACUNCULUS MEDINENSIS. 



'395 



entrance into the body before the worm appears at the surface, 
and Busk says it may even be eighteen months. 

Diagnosis. — The diagnosis can only be made when the worm 
can be felt under the skin like a coil of string, and its nature 
will become more certain, if it changes its position, before it 
forms the tumor preliminary to its exit. 

Prognosis. — This is favorable unless violent inflammation 
occurs before or after the opening of the abscess, the conse- 
quences being especially serious when the worm is broken dur- 
ing extraction. 

Treatment. — From what has been said the indication clearly 
is to remove the worm entire, or to bring about its death before 
it can discharge its embryos. This latter indication has been 
so effectually accomplished by Emily, a French naval surgeon, 
as to almost supersede other methods, the old plan of gradu- 
ally winding the extruding pregnant worm on a quill or piece 
of wood having been justly abandoned as dangerous. 

With a hypodermic syringe, Emily * injected a solution of 
i in iooo perchlorid of mercury, either directly into the worm, 
if extruding, or if still under the unruptured skin, a few drops 
are injected through several punctures as near the coil as possi- 
ble. Both methods kill the parasite and its embryos. In the 
first case, after twenty-four hours, the worm can be wound out 
without resistance. In the second she is absorbed without set- 
ting up any inflammation, a perfect cure being obtained in three 
or four days. 

The improved extraction plan of Forbes, Dick, and Manson 
is to douche the part frequently with water, as related above, 
when the uterus will be gradually and naturally emptied of the 
embryos. This takes from fifteen to twenty days, and she no 
longer resists extraction, and will often issue forth spontane- 
ously; if not, a little compulsion may be safely exercised, the 
worm being wound out on a quill or cedar pencil, but this must 
not be done until all the embryos are out. The saving of time 
by Emily's plan entitles it to the preference. 

* Brit. Med. Jour., July 7, 1894, p. 23. He treated on the Niger 105 
cases in three months, and others have indorsed his statements. 



i 39 6 DISEASES OF THE SKIN. 



CYSTICERCUS CELLULOSE CUTIS. 

Rokitansky first demonstrated the presence of the cysticercus 
of taenia solium in the subcutaneous tissue, and cases have been 
reported by Lewin,* Guttmann,f SchifI4 and others. Indeed, 
Kuchenmeister and Ziirn state that at least five per cent, of 
all cases of taenia solium affect the skin. Most of the cases 
have been observed in North Germany, where half-cooked pork 
is more frequently eaten than in other countries. These small 
hydatids are rarely single, and usually very numerous, but do 
not appear together. They occur chiefly on the back and sides 
of the trunk, less frequently on the extremities. They are really 
subcutaneous, and appear externally as oval or roundish pea- 
sized tumors, as a rule, but varying from a lentil to a walnut. 
The skin over them is normal, and when the animal is alive the 
tumor is firmly elastic and movable. After death they shrink 
and become hard nodules, which are often calcified, but they 
take two or three years to become thus completely obsolete. 
They rarely give rise to pain or other inconvenience, unless 
they are unusually large, or exposed to pressure, or in the rare 
event of suppuration taking place; capillary hemorrhages may 
sometimes occur from degeneration of the vascular walls. 
Their interest lies chiefly in their diagnosis. Pye-Smith § 
showed a man of about thirty to the Dermatological Society in 
April, 1892, in whom there was a large number of pea- to 
marble-sized nodules imbedded in the subcutaneous tissue, 
chiefly of the upper part of the trunk, but also in the limbs, 
head, and neck, some of them being in lines. The skin over 
them was unaltered; they were quite firm to the touch, painless, 
and felt more like nodules than cysts, and this has been so in 
the other cases I have seen. Their real nature was not sus- 
pected until one was excised from the forehead, when they were 
found to be cysts containing embryos with a single circle of 
alternately large and small hooklets. Perrin read a case at the 

* Viertelj. f. Derm. u. Syfth., vol. iv., Heft 4. and vol. xxvi. (1894), 
Heft 1 and 2. 

\ Berl. klin. Woch., No. 26, 1877. 

% Lancet, vol. i. (1879), p. 753. 

§ " Case of Multiple Cysticerci of the Subcutaneous Tissues," Brit. 
Jour. Derm., November, 1892, illustrated. 



CYSTICERCUS CELLULOSJE CUTIS. 



1397 



Dermatological Congress at Vienna, probably clue to auto- 
inoculation. Galatti's case, a girl of ten, had a single hazelnut- 
sized growth of cartilaginous consistency just above the 
umbilicus. 

These cysts may be mistaken for rheumatic nodules, gum- 
mata, lipomata, sarcomata, carcinomata, and sebaceous cysts. 
Careful consideration of all the circumstances * and symptoms 
will lead to a suspicion of their nature, which will be confirmed 
by excision, or even puncture, of one of the tumors, when the 
hooklets will be discoverable in the escaping fluid. 

Echinococcus hydatid has also been reported as having been 
found in the skin by Davaine. It forms a semi-translucent, 
fluctuating tumor, with the skin over it unchanged. The para- 
site dies in one or two years, and the diagnosis would probably 
not be made without an exploratory puncture and discovery 
of the hooklets with the microscope. 

Three cases of encapsuled rediae, or embryos of the distoma 
hepaticum, have been collected by Kuchenmeister. They were 
only diagnosed after removal. 

Sharkey has found the ova of Bilharzia haematobia in some 
human skin sent to him from Cairo. 

Arnold f of Bulawayo reports a case of what appeared to be 
boils, but closer examination showed that each lesion contained 
a larval form of worm one-third of an inch long. 

Ankylostoma larvae. Hitherto it has been supposed that 
this parasite obtained entrance to the body only through the 
mouth, but Looss I suspecting that he had himself been infected 
through the skin, put a drop of water containing larvae on the 
skin of a leg which was to be amputated in an hour. After- 
examination showed that the larvae gained entrance chiefly by 
the hair follicles, then penetrated the papilla, and thence into 
the subcutaneous tissues. 

* De Amicis had two cases who also had epileptiform convulsions, and 
in two other cases that I have met with this has been the first symptom 
to attract the patient's attention. 

f Lancet. April 2, 1898, p. 960, with figure of parasite. 

%Centralblatt f. Bakt., May 30, 1901. Abs. Brit. Med. Jour. Efizt., 
November 23, 1901. 



APPENDIX. 



AN ANALYSIS OF FIFTEEN THOUSAND CASES OF 
DISEASES OF THE SKIN. 

Statistics of diseases of the skin require a good deal of qualification 
before they can be accepted as tests of the frequency of any particular 
disease. Thus, the cases which are rebellious to treatment, such as tinea 
tonsurans, naturally gravitate in undue numbers to a special department. 
Cases which are relievable, but seldom curable, like both forms of lupus 
•and psoriasis, and to a less extent tertiary syphilis, come back year after 
year, and are counted as fresh cases. On the other hand, cases which are 
-easily recognized or easily curable, such as herpes zoster, molluscum con- 
tagiosum, etc., have a much smaller place than their real frequency would 
entitle them to. Again, very rare diseases, and even the less common 
forms of disease, such as lichen planus, with which many practitioners are 
unfamiliar, naturally find their way in undue proportion into dermatologi- 
cal statistics; while many new growths, such as fibroma, epithelioma, 
rodent ulcer, and vascular nevus, are quite as, or even more likely to go 
to the general surgeon, who also retains many cases of lupus and syphilis. 
Nevertheless, while the numbers must be taken, with these and other 
qualifications, as only roughly approximate, they have, if in sufficiently 
large numbers, a certain value, especially when compared with those of 
other countries and other workers. The round number fifteen thousand 
has been chosen because, while it is large enough to avoid the errors of a 
small series, it allows the ratio per thousand to be readily computed. The 
cases are, however, consecutive; but those patients who were admitted 
into the hospital directly — i. e., without passing through the out-patient 
department — are not included, so that many cases of rare diseases, such 
as xerodermia pigmentosa, sclerodermia, leprosy, etc., have passed under 
my cognizance, but are not mentioned here, the tables being simply an 
out-patient record. But if tables of hospital practice must be taken with 
qualifications, those of private practice are still more open to fallacy, 
and only in quite a moderate number of diseases can a comparison be- 
tween their frequency in rich and poor can be fairly made. 

I have taken the patients of my last seven case books as the most 
representative of the class of cases which seek advice from a consultant 
with a special reputation for diseases of the skin. In one way private 
statistics are more accurate, as the same patient would not be counted 

1399 



i 4 oo APPENDIX. 

twice because he came in a different year. Readily curable and readily 
diagnosable cases are conspicuous by their absence or very small numbers. 
Few cases come to me which have not undergone previous treatment by 
their family practitioner, his extremity being my opportunity. Partly for 
this reason and partly that a large proportion of persons, unless they are 
very wealthy, are unwilling to pay high fees for young children, unless 
the disease is very obstinate or disfiguring, the proportion of children in 
private consulting practice is very much less than would be anticipated, 
especially when compared with hospital practice. Allowing for all these 
modifying circumstances, of course there are differences in the relative 
frequency of skin diseases in rich and poor. What may be termed dirt 
diseases are, naturally, nearly absent, and even when present due to other 
causes. Thus pediculosis as it affects the head and body, which con- 
stitutes 4 per cent, in hospital practice, only amounts to one in one thou- 
sand in private. As regards pediculi pubis, owing to its being acquired 
chiefly in impure intercourse, it is even more common among the well- 
to-do; but this disease does not figure largely in my practice. Scabies, on 
the other hand, stands higher than would be expected in the list — over 
i per cent., as compared to 8 per cent, in public work; but this is because 
scabies in clean people seldom develops to any great extent, and is so 
often unrecognized by the family practitioner, and it is chiefly as a result 
of errors of diagnosis that it comes under my cognizance. Tinea ton- 
surans also stands high — viz., as 2 per cent, to 10 per cent. This, how- 
ever, underestimates the frequency of it, as for the most part only the 
inveterate cases come under my notice in private. On the other hand, 
few cases of tinea circinata are in the list, as the family doctor cures it 
as easily as I should do. Impetigo contagiosa is a rare disease among the 
well-to-do; 1 per cent, as compared to 10 per cent., as the conditions for 
acquirement and propagation less often obtain. In lupus vulgaris the 
difference in the frequency is much greater than it appears — viz., as 1 to 
1.3 per cent. The reason is that, on account of its obstinacy, nearly all 
cases of lupus vulgaris among the " classes" have consultant advice, if 
they can afford it. Lupus vulgaris is really a rare disease among the 
wealthy; the majority of sufferers, even in private practice, belong to the 
less prosperous members of the community. Lupus erythematosus is 
quite on another footing; for while it is only half as common as lupus 
vulgaris at the hospital, there are nearly twice as many in private — another 
argument against the two diseases being etiologically identical. The 
difference in frequency between eczema and psoriasis in private and 
hospital practice is not great, and as regards psoriasis, is more than ex- 
plained by the recurrences in hospital practice being counted as new 
cases, while the seborrheids have not been differentiated from eczema 
in the hospital statistics; but lichen planus is twice as frequent in private 
— viz., as seven to three — because not only does it yield to treatment 
slowly, but it is often not recognized by the practitioner; possibly also 
the neurotic element in its etiology finds freer scope among the clientele 
of the consulting room. 

Diseases involving a loss of hair figure very high in the private statistics 



APPENDIX. 



1401 



— viz., 10 per cent, for ordinary forms of baldness and 3 per cent, for all 
forms of alopecia areata. This may be accounted for partly from this 
class of people being more sensitive on the subject; but probably a great 
part is personal, and the very large proportion — nearly eight hundred out 
of five thousand — has had a lowering influence in the proportion of other 
diseases. Its rebelliousness to treatment is probably another reason of 
the frequency of alopecia areata, as well as its conspicuous disfigurement; 
but believers in a universal neurotic theory for all cases would probably 
explain it as due to the greater sensitiveness of the nervous system of the 
wealthier classes; against this is to be set f he preponderance of males. 
Rodent ulcer has also a high place — seven per thousand. As the derma- 
tologist sees it, it is generally in an early stage, the more advanced cases 
usually resorting to the general surgeon. As might be expected, acne 
vulgaris and rosacea have a much higher ratio than in hospital patients, 
who, as a class, would not trouble about the slighter forms of those dis- 
eases. Many other comparisons might be made, but enough has been said 
to show that many other considerations come in besides the mere figures 
in comparing the two tables, and in estimating the relative frequency 
of diseases of the skin. 



ANALYSIS OF 10,000 CASES OF DISEASES OF THE SKIN 
IN HOSPITAL OUT-PATIENT PRACTICE. 



Class I. Hyperaemiae : 

Erythema 56 

Class II. Exudationes : 



Erythema exudativum, 
eluding 16 erythema ir 
Urticaria .... 

Prurigo 

Eczema, all forms . 
Dermatitis repens . 
Impetigo contagiosa 
Furun cuius . . . 
Carbunculus . . . 
Herpes zoster . . 
facialis . . 
Pompholyx . . . 
Pemphigus . . . 
Dermatitis herpetiformis 
Hydroa vacciniformis 
Psoriasis .... 
Pityriasis rubra . . 
" rosea . . 



114 

440 

21 

2630 

5 
961 

32 
3 
61 
52 
11 

33 
10 
1 
718 
14 
40 



Lichen planus .... 
" scrofulosus . . . 
" pilaris .... 
" circinatus (sebor 
rheic dermatitis) 
Vaccination eruptions 
Dermatitis, unclassified . 

artificialis 
Drug eruptions .... 



98 
14 

7 

46 
8 

24 
4 
8 



Class III. Haemorrhagiae : 
Purpura n 



Class IV. Hypertrophias : 

Ichthyosis and xerodermia . 54 

Papilloma 7 

Keratosis palmae .... 5 

Sclerodermia ..... 2 

circumscribed 6 

Elephantiasis ..... 6 



1402 



APPENDIX. 



Class V. and VI. Atrophies 
and pigment anomalies : 



Chloasma .... 
Nsevus pigmentosus 
Leukodermia . . 



Class VII. Neuroses: 

Pruritus 90 

Class VIII. Neoplasmata: 
{a) Degenerative: 



Molluscum contagiosum 
Xanthoma 



(b) Infiltrating: 

Lupus vulgaris . . . 
" erythematosus 

Scrofulodermia . . , 

Syphilis, secondary 
" tertiary 

" congenital . 

Lepra 

(c) Benign: 

Keloid ...... 

Fibroma 

Nsevus vascularis . , 
Telangiectasis . . 



(d) Malignant: 

Paget's disease 
Rodent ulcer . 



20 
3 



127 
63 

15 

540 

73 
6 



Class IX. Morbi Appendicium : 

(a) Sweat glands: 

Miliaria 30 

Hyperidrosis 13 

Chromidrosis ...... 2 



(b) Sebaceous glands: 

Seborrhea . . . . 

Milium (grouped) . . 
Comedones (grouped) 

Acne vulgaris . . . 

rosacea . . . 
' ' varioliformis 

Adenoma sebaceum . 



77 

1 

7 
245 
199 

15 

1 



(<r) Hair Follicles: 

Canities 1 

Alopecia 5 

areata 253 

Sycosis 76 

Folliculitis 5 



(d) Nails: 
Trophic nail affections 



21 



Class X. Hyphomycetic 
parasites : 

Favus 3 

Tinea Tonsurans, including 

26 kerion 1031 

Tinea circinata 272 

" barbae (severe) ... 6 

" versicolor .... 29 

Class XI. Animal parasites : 

Scabies 796 

Pediculi capitis 192 

" corporis .... 197 

" pubis 4 

Class XII. Exanthemata: 

Varicella 30 

Other exanthemata ... 10 



APPENDIX. 



1403 



ANALYSIS OF 5000 CASES OF DISEASES OF THE SKIN 
IN PRIVATE PRACTICE. 



Class I. Hyperaemiae : 

Erythema congestivum . 
Recurrent scarlatiniform erythema 



Class II. Exudationes: 

Erythema exudativum . 

" iris .... 

Peliosis rheumatica 

Urticaria 

pigmentosa 
Eczema, all forms . 
Dermatitis repens . 
Impetigo contagiosa 
Furunculus .... 
Carbunculus .... 
Herpes zoster .... 
" facialis 
" progenitalis 
Pompholyx .... 
Pemphigus .... 
" foliaceus 

" vegetans 

Dermatitis herpetiformis 

aestivalis and hiemalis 
Psoriasis . .... 
Pityriasis rubra 

" rosea . . . 

Lichen planus .... 
" variegatus . 
" acuminatus . 
" pilaris .... 
" circumscriptus of Vidal 
Dermatitis venenata 

" Rontgen rays 

" medicamentosa 

" gangrenosa . 

Vaccinides .... 

Class III. Haemorrhagiae : 

Purpura . . . 

Class IV. Hypertrophiae : 

Ichthyosis .... 

hystrix 
Verruca ..... 



M. 


F. 


8 


15 


1 




12 


28 


7 


17 


1 


1 


66 


126 


1 


— 


516 


460 


2 


2 


34 


17 


17 


11 


3 


— 


12 


6 


4 


8 


6 


2 


3 


3 


3 


7 


— 


1 


2 


1 


20 


10 


5 


16 


153 


148 


6 


10 


26 


36 


52 


61 


2 


— 


— 


1 


2 


1 


4 


2 


12 


14 


1 


— 


5 


8 


1 


5 


2 




2 


1 


11 


20 


2 


1 


21 


26 



Total. 



40 

24 

2 

192 

1 

976 

4 

5i 

28 

3 

18 

12 

8 

6 

10 

1 

3 

30 

21 

301 

16 

62 

"3 

2 
1 

3 

6 

26 

1 

13 
6 



3i 

3 
47 



1404 



APPENDIX. 



Class IV. Hypertrophiae (Continued) 

Clavus 

Keratosis palmse et plantas 

" nigricans 

Sclerodermia diffusa 

circumscripta . 

Class V. Anomalies of pigmentation : 

Lentigo ...... 

Chloasma 

Arsenical pigmentation . 
Leuko- and melanodermia . • 
Orange staining .... 
Addison's disease .... 

Class VI. Atrophia* : 

Xerodermia pigmentosa . . 

Striae atrophica? .... 

Class VII. Neuroses: 

Pruritus, general .... 

" local .... 

cerebri .... 

Class VIII. Neoplasmata: 

(a) Degenerative : 

Molluscum contagiosum 

Xanthoma 

" diabeticorum . 

{&) Infiltrating: 

Lupus vulgaris .... 

Scrofulodermia .... 

Erythema induratum 
Lupus erythematosus . . . 

Syphilis 

Lepra 

(c) Benign: 

Keloid . . . 

Fibroma (single) .... 

Myoma multiplex .... 



M. 


F. 


5 
6 
i 


3 
4 


4 


3 

5 


6 


ii 


2 
2 

7 
3 


9 

3 

14 

I 




I 


i 




24 

42 

5 


15 

4i 

3 


3 


9 

i 


i 




13 

2 


36 
4 


14 
99 
io 


76 

28 

4 


7 

i 


4 
3 

i 



APPENDIX. 



1405 



Scirrhus, secondary 
Epithelioma 
Rodent ulcer 
Paget's disease 
Sarcoma . 
Mycosis fungoides 
Furunculus orientalis 
Papillary growths . 
Granuloma annulare 



Class IX. Morbi appendicium 
{a) Sweat-gland diseases : 



Miliaria and other sweat inflammations 

Hyperidrosis 

Bromidrosis 

Hydrocystoma 



{b) Sebaceous gland diseases: 



Seborrhea . . 

Seborrheids .... 
Sebaceous cyst 

Milium 

Hypertrophied sebaceous gland 

Comedones only 

Acne vulgaris .... 

" rosacea .... 

" follicularis 

varioliformis . 

" keratosa .... 



(t) Hair follicles and hair diseases 



Tinea nodosa . 
Trichorrhexis nodosa 
Canities 
Ringed hair 
Hirsuties . 
Seborrheic alopecia 




(c) Benign (Continued): 

Naevus pigmentosus 

vascularis .... 
Lymphangiectodes .... 
Lymphangioma tuberosum multiplex 
Adenoma sebaceum 
Telangiectasis .... 



{d) Malignant 



97 



39 
63 



2 

1 

1 

33 



15 



63 

115 

2 

2 

1 

3 
222 

243 
6 

5 



2 
12 J 18 

1 1 

-, 87 
159 307 



Total. 



18 

12 

3 

1 

1 

45 



20 

14 

3 

1 



81 
212 

2 
2 
1 
3 
3ii 
306 
6 
4 
5 



2 

2 

3o 

2 

87 
466 



406 



APPENDIX. 



(c) Hair follicles and hair diseases (Continued) 

Alopecia, other causes 

areata, all forms .... 

Sycosis 

Folliculitis 

{d) Nail diseases : 
Various 

Class X. Hyphomycetic diseases : 

Tinea tonsurans 

44 cruris * 

44 circinata ...... 

" barbae 

versicolor 

Class XI. Animal parasites: 

Scabies . 

Pediculosis capitis 

44 corporis ..... 

pubis 

Ixodes 

Bug-bites 

Unclassified 

Totals 



M. 


F. 


7 


20 


158 


133 


30 


— 


17 


7 


13 


21 


72 


3i 


20 


1 


7 


8 


16 


— 


9 


6 


45 


13 


1 


4 


4 


7 


2 


— 


1 


— 


1 


— 


36 


58 


2240 


2843 



Total. 



27 

291 

30 

24 



34 



103 
21 

15 
16 



15 



58 

5 
11 

2 
1 

1 
94 



;o8 3 



CLINICAL EXAMINATION AND STAINING OF BACILLI 
AND FUNGI. 

This Section is by Mr. George Pernet. 



Introductory Remarks.— To avoid repetition, cover-glass preparations 
are to be made in the following manner: A small quantity of the pus or 
a drop of the fluid to be examined is placed on a clean cover-glass. An- 
other clean cover-glass is then placed on the material, and the two are 
gently pressed together, and carefully separated, so as to spread the pus 
or fluid as evenly as possible in a thin layer over the respective cover- 
glass surfaces. (Or two clean slides can be used in the same way.) The 
cover-glasses are then allowed to dry. The films are next fixed by pass- 
ing the cover-glasses three times slowly through a spirit-lamp name.' 

All stains should be freshly prepared, if possible, and filtered before 
using. 



APPENDIX 1407 

Before mounting in Canada balsam the preparations should be care- 
fully dried, to get rid of all moisture, either with blotting (or filter) paper, 
or by holding the cover-glass, with film upwards, high up over a flame. 

For other methods, staining of sections, and other details the following 
works can be consulted: " The Essentials of Practical Bacteriology," by 
H. J. Curtis, 1900; " Technik der histologischen Untersuchung," C. von 
Kahlden, Jena (1900), or Morley Fletcher's translation; " Methods of 
Pathological Histology " (1894); " Dermato-Histologische Technik," Max 
Joseph and Georg Lowenbach, 2d ed. (1901). Also the standard works 
on Bacteriology, etc., by Professors Edgar Crookshauk, Robert Boyce, 
Sims Woodhead, and others. 



I. ACTINOMYCOSIS (Actinomyces). 

The yellowish * grains examined in glycerin, the cover-glass being 
gently pressed on to the slide, show the characteristic rosettes of clubs. 
Or prepare films and stain by (a) Gram's Method. 

1. Two to five minutes in a saturated anilin gentian violet solution (or 
in a saturated methyl violet solution prepared w T ith i\ per cent, aqueous 
carbolic acid). 

2. Two minutes exactly in Lugol's iodin potassic iodid solution 
(iodin 1 part, iodid of potassium 2 parts, distilled water 300 parts = 1 : 
2 : 300). 

3. Rinse in absolute alcohol until no more violet color comes aw r ay (5 
to 10 minutes). 

4. Wash in w T ater. Dry. 

5. Mount in xylol-Canada balsam. 

After washing and drying {vide supra, 4), films can be counterstained 
with a 5 per cent, watery eosin solution for a half minute; then 4 and 5 
as above 

II. ANTHRAX (Malignant Pustule). 
(Bacillus Anthracis.) 

Clean the part with soap and ether, then make small punctures with a 
a scalpel in the peripheral parts of the lesion. Examine the blood (cover- 
glass films). If seen early enough, the contents of the earl}'- bulla or 
pustule could be examined. Cases usually first come under observation 
when the central eschar has commenced to form or is formed. The bacilli 
are in great abundance under the eschar and about its edges. 

Owing to the large size of this bacillus, it can be readily seen with an 
ordinary \ or \ (an oil immersion is not necessary), even without staining. 
(Nicolle and Morax.) 

* According to Bostrom, the color of the grains is by no means so uni- 
form and constant as believed. They vary from gray to yellow, green, 
and brown. — Kanthack, \n Journ. of Path, and Bacteriology, October, 
1892, p. 146. 



1408 APPENDIX. 

Cover-glass preparations can be stained by Gram's method {vide supra, 
i.), or with a carbol-fuchsin (vide infra, v.). 

A simple method is to immerse cover-glass for five minutes in common 
methyl violet solution, wash out most of the stain with absolute alcohol, 
clear with xylol, and mount in Canada balsam. (Barker.) 

III. FAVUS (Achorion Schonleinii). 

( Vide infra, vii. as for Ringworm.) 

When yellow discs and cups are present, the material on the under 
surface of the crusts should be examined, as for ringworm scrapings. 

IV. GLANDERS (Bacillus Mallei). 

Cover-glass preparations of the pus do not stain by Gram's method. 

Has special affinity for Lofner's methylene blue. To stain: 

i. Five minutes in methylene blue. 

2. Wash in water. 

3- Dry. 

4. Canada balsam. 

Note. — MM. Nicolle and Morax point out that as the microscopical 
examination of the pus in man is frequently negative, it is necessary in 
such cases to make use of the inoculation test (male guinea-pigs). Migula 
(in " System der Bakterien," vol. ii. p. 199) makes the same remark, add- 
ing that the differential diagnosis of the bacillus mallei can only be made 
with certainty by cultivation and inoculation (male guinea-pig). 

V. LEPROSY (Bacillus Leprae, or Hansen's Bacillus). 

A nodule is clamped at its base to render it bloodless (clamps have 
been devised for this purpose, but carefully squeezing with curved forceps 
will be found sufficient). It is then incised with a scalpel. Clear fluid 
then oozes out, and its quantity can be increased by pressure about the 
base of the nodule. (It is important not to get blood mixed with the 
exuding fluid.) A clean cover-glass is applied to the fluid, and films pre 
pared (vide Introductory Remarks ) 

Similarly, films may be prepared with the secretion of ulcers, or with 
the scrapings of broken-down mucous membrane lesions (uvula, etc.) 

The bacilli readily stain by the following methods : 

a Ziehl-Neelsen Method. 

1. Five minutes in warm carbol-fuchsin solution (fuchsin 1, alcohol 10, 
concentrated carbolic acid 5, distilled water 100). The solution is heated 
in a test tube over a spirit-lamp flame, but not boiled, and poured on to 
cover-slip held by Cornet forceps. 

2. Wash in water. 

3. Place in 5 per cent, watery sulphuric acid, or a 15 per cent, watery 
nitric acid solution, until the film is completely decolorized. 

4. Wash in water. (If the pink color reappears the cover-slip can be 
returned to the sulphuric acid solution, and back to water.) 



APPENDIX. 1409 

5. One to two minutes in a 1 per cent, watery methylene blue solution. 

6. Wash thoroughly in water, and carefully dry. 

7. Mount in Canada balsam. 

j3 Gram's Method can also be employed (vide supra, i.). 
There are other methods, such as Gabbet's, etc. 



VI. MADURA FOOT (MYCETOMA) (Streptothrix Madura of 

Vincent). 

(As for Actinomyces, vide supra, i. See also p. 1349.) 

VII. RINGWORM (1. Microsporon Audouini. 2. Trichophyton Megalo- 
sporon Endothrix. 3. Trichophyton Megalosporon Ectothrix). 

Tinea Tonsurans. 

Broken or short stumps should be selected with a lens, and placed on 
the end of a slide and treated with a drop or two of ether, to get rid of 
fat, ointment, etc. The hairs are then moved on to the center of the 
slide with a needle on holder, and examined in a drop of liq. potassae B. P., 
the cover-glass being gently applied. As the preparation "clears," the 
fungus will be readily seen. 

If a permanent preparation is required, it can be stained as follows: 

a Adamson's Method.* 

When the preparation treated in the above manner has reached the 
desired stage of " clearing," gently wash under cover-glass a few drops 
of 15 per cent, mixture of alcohol in distilled water. The cover-slip is 
then removed. The specimen (either on slide or cover-glass) is treated 
with more of the 15 per cent, alcohol mixture, to get rid of the excess of 
potash, and it is then fixed by drying carefully over the flame of a spirit 
lamp. 

Then: 

1. Stain in gentian anilin violet for fifteen to sixty minutes. 

2. One to five minutes in Gram's iodin solution. 

3. Decolorize in anilin oil two or three hours or longer. 

4. Remove anilin oil with blotting paper, and 

5. Mount in Canada balsam. 

,3 A more rapid method is the following of Brongersma of Amsterdam. 

1. Place stump to be examined on a slide, and get rid of fat with ether. 

2. Add a little anilin gentian violet solution. (Five minutes.) 

3. Dry with blotting (or filter) paper carefuhy, and add potassium 
iodid iodin solution. (One to five minutes). 

4. Dry as above, then add a drop or two of anilin oil, move the slide, 
then add a drop or two of anilin oil, to which a drop of hydrochloric acid 
has been added. 

5. When as much stain as possible has been got rid of, again add 
anilin oil. 

6. Xylol. 

* Brit. Journ. Derm., vol. vii. (1895), p. 376. 



i 4 io APPENDIX. 

7. Mount in Canada balsam. 

(The writer has found that stumps previously clarified in liq. potassae 
B. P. can be made use of, and give good results by this method). 
(Both the above are modified Gram methods.) 

Tinea Circinata. 

With a scalpel thoroughly scrape the affected skin, and treat the scrap- 
ings in the same way as above, the scales being fixed by passing three 
times through a spirit-lamp flame. 

Tinea Unguium. 

Scrape the affected nail thoroughly with the sharp edge of a slide. 
Clarify in a 40 per cent, solution of potash. This gives quicker results 
than the weak B. P. solution, but in any case a thorough and prolonged 
examination should be made, if necessary. 

To stain (vide supra). 

VIII. TUBERCULOSIS (Bacillus Tuberculosis, or Koch's Bacillus). 

(Same methods of staining as for Bacillus Leprae ; vide supra, v.) 



NATURAL MINERAL WATERS AND SPAS. 

BOTTLED MINERAL WATERS. 

The dermatologist makes use of the purgative, alkaline, and ferruginous 
nrtural mineral waters in the same way, and for the same purposes, as 
the general physician. The bromo-iodin and arsenical waters are of 
more special application. 

PURGATIVE WATERS. 

The directly purgative waters owe their action chiefly to sulphates of 
soda and magnesia in varying proportions. The principal are Piillna, 
Friedrichshall, Hunyadi-Janos, jiEsculap, Apenta, and Victoria Ofener. 

Of these I use Friedrichshall for a mild and Hunyadi-Janos for a stronger 
aperient, but some prefer Piillna to Friedrichshall, as the latter contains 
a large quantity of chlorid of sodium, which they think is injurious in 
skin diseases; but this is not a sound objection, in my opinion. When 
the sulphates of magnesia and soda are in nearly equal proportions, the 
taste is much less objectionable than when one or other preponderates. 
For this reason I prefer Hunyadi-Janos, and the less known Hunyadi- 
Taszlo, which is a trifle stronger, to the more powerful ^sculap and 
Victoria Ofener; the last being the strongest purgative water known, but 
it contains a large preponderance of sulphate of magnesia, and is pro- 
portionately nasty. The "Franz Josef" spring is also a very strong 
aperient, and contains equal parts of the sulphates of soda and magnesia, 
240 in 10,000. The dose of nearly all these is a wineglassful and upwards 



APPENDIX. 141 1 

freely diluted with tepid water, and taken in the morning before break- 
fast. They are especially useful in fecal accumulation, which always 
aggravates, even when it does not produce, inflammatory diseases, such 
as eczema, acne, etc. 

ALKALINE WATERS. 

These are very numerous. Those of Vals, Vichy, Ems, and Karlsbad 
may be specially mentioned. Vals and Vichy are simply alkaline, and 
owe their properties chiefly to the bicarbonate of soda they contain. 
Those of Vals are the strongest, especially the Magdeleine, Precieuse, 
and Desiree springs. Those of Vichy are more generally employed, and 
though there are several springs they are practically of the same com- 
position and value. They are useful to many dyspeptics with strongly 
acid urine, and in any skin disease, such as eczema or psoriasis, in which 
that condition is present; they should not, however, be continued too 
long, or they may aggravate instead of alleviating. A tumblerful of 
either Vals or Vichy may be taken twice a day. 

Karlsbad Sprudel salt is a laxative as well as an alkaline; its chief con- 
stituents are sulphate and bicarbonate of soda, with a moderate quantity 
of chlorid of sodium. It is a great favorite of mine in gouty states and 
inactivity of the liver. A heaped teaspoonful of the dried salt dissolved 
in at least two-thirds of a tumblerful of warm water, and, taken before 
breakfast, generally gives one or two free evacuations, and there is no 
further trouble. It may be taken two or three times a week. 

FERRUGINOUS WATERS. 

The waters from Spa, Pyrmont, and Schwalbach are those chiefly em- 
ployed. 

Spa. — The Pouhon and Pouhon du Prince de Conde are the chief iron 
springs. That from the Prince de Conde is the only one imported. The 
iron is in the form of bicarbonate, along with sodic, magnesic, and calcic 
bicarbonates. Owing, however, to the lime being in small quantity, it 
has the great advantage of retaining its iron for a long period after being 
bottled; while most ferruginous waters contain a great deal of lime, 
which leads to the speedy deposition of the iron from solution. 

Schwalbach. — The water from the Stahlbrunnen and Weinbrunnen is 
imported into England. The Stahlbrunnen is stronger and more stable 
from its containing less lime. 

Pyrmont. — The Trinkbrunnen and Neubrunnen are a little stronger 
as regards iron than the respective springs above mentioned of Schwal- 
bach, but they contain enormous quantities of lime. 

On the whole, therefore, the Spa waters are the best; from one to four 
tumblers or more a day may be given in anemic and chlorotic states, or 
whenever iron is indicated. They are especially suited for patients with 
weak digestions, who do not tolerate iron in the cruder forms, and for 
whom expense is not a great object. A fair imitation may be made by 
adding ten minims of the liquor ferri perchloridi B. P. to half a pint of 
seltzer water. 



1 4 i 2 APPENDIX. 

Flitwick. — This is a remarkable spring in Bedfordshire, containing 
rather less than 170.8 grains of persulphate of iron to the gallon. It 
keeps well in bottles, but whether, as asserted, the iron is in a readily 
assimilable form requires further experience; it is well worth trying. 

ARSENICAL WATERS. 

The chief are those of Levico, Roncegno, La Bourboule, and Royat. 

La Bourboule is a sodio-chlorureted and bicarbonated arsenical water, 
containing twenty-eight milligrams of sodic arseniate to the liter, or 
nearly two grains to the gallon. The other salts both of this and Royat 
are very similar to those of the blood. A large tumblerful is the average 
dose. 

Royat. — The Saint Victor spring is the strongest; it contains only one- 
sixth of the quantity of arsenic contained in the waters of La Bourboule, 
but has more iron. 

Levico is said to be the strongest arsenical water known, containing 
.086879 arsenious acid in 10,000 parts, or about one-twelfth of a grain per 
pint; it also has a considerable quantity of iron in the form of persulphate. 
The usual dose is a tablespoonful. 

Roncegno is very similar to Levico, and the dose is the same. These 
waters are used chiefly in anemia and psoriasis, and like the ferruginous 
waters, are adapted for weak digestions and long purses. 

BROMO-IODIN WATERS. 

These are suitable for strumous and syphilitic subjects. The chief are 
those of Kreuznach, Purton, and Woodhall. The last is the strongest 
known, and contains nearly five grains of bromin and two- thirds of a 
grain of iodin to the gallon. 

THE SPAS. 

Far more efficacious than swallowing the imported waters is a visit to 
the spas themselves. It must, however, be borne in mind that there are 
many other elements beside the composition of the waters which make 
for success in the restoration of the patient. Among these are the 
climatic conditions, and the consequent change of air and scene, the regi- 
men and regular hours, as well as the withdrawal from many of the temp- 
tations of society life. At some spas the topical use of the baths plays 
an important part; and last, not least, is the influence of hope and faith 
engendered in the carrying out of a new treatment in which there ap- 
pears to be a little mystery, and in which the very expense and trouble 
stimulate the patient to do all that he can to get well, instead of carry- 
ing out the treatment in the half-hearted way in which patients at home 
are too apt to subordinate the means of cure to their engagements and 
convenience. Although, therefore, to such self-indulgent patients, a 
suitable spa may be the best means of cure, it must not be supposed 
that they are necessary to success, provided that a patient will give him- 



APPENDIX. 141 3 

self up to treatment at home, as completely as may be necessary for the 
kind of case. 

A few of the principal spas will be specially noticed in alphabetical 
order. 

Aix-la-Chapelle, Germany, is in a bowl-shaped valley on the Lower 
Rhine, near the Belgian and Dutch frontiers. The climate is mild, and 
the season is from May to October. There are four chief springs: the 
Kaiserquelle, the Quirinusquelle, the Rosenquelle, and the Cornelius- 
quelle. They are hot, sulphureted waters, with a fair amount of chlorid 
of sodium. The Kaiserquelle, 131 F., is the hottest; the Corneliusquelle, 
113. 6o°, the least so; in other respects, they are practically the same. 
They are chiefly employed for psoriasis and tertiary syphilis, for the latter 
in conjunction with mercurial inunctions. The system employed has 
obtained great celebrity and success, and is thus described by Berkeley 
Hill in his work on Syphilis: 

"The patient is restricted to a tolerably precise regimen, which ex- 
cludes bodily fatigue, excess of all kinds, and enforces regular hours of 
rest and gentle exercise. The diet is limited; many articles, such as 
fruit, likely to cause relaxation of the bowels, are forbidden, while milk 
is largely prescribed. The daily course consists of a bath in the hot 
sulphur water, and during the sweating thus induced, a dram of mer- 
curial ointment is rubbed by an attendant into the skin of the patient. 
In this condition he remains for one or two hours, drinking a pint or 
more of the sulphur water during his sweat. He then rises, walks out, 
dines, and then walks again if weather permit. In the evening he goes 
early to bed, and thus prepares himself for a repetition of the treatment 
next day. Great care is taken to prevent salivation, both by watching 
the effect of the treatment and by insisting upon the use, several times 
daily, of an alum or other astringent mouth-wash. Tonics are also ad- 
ministered to weakly persons, and the treatment is modified in its strict- 
ness to suit their condition. The course occupies usually six or seven 
weeks, comprising forty to fifty rubbings. In this time all symptoms 
have usually disappeared, at least for a time, and the patient is dismissed 
by his physician, with an injunction to return for another course after 
an interval of two months." 

Aix-les-Bains, France, on Lake Bourget, in a pleasant valley. The 
climate is good, but hot in the season (July and August), and May, June, 
and September are preferable. The waters are from two chief springs, 
the Eau de Soufre and the Eaux d'Alun (so called), which are practically 
identical, and, like those of Aix-la-Chapelle, hot and sulphurous. Their 
temperature is 112 to 116 F. There are three springs at Mariioz, about 
a mile distant from Aix-les-Bains, which are strongly sulphurous, but 
their temperature is only 57 F. The neighboring springs of Challes are 
of similar characters. Aix-les-Bains is chiefly resorted to in chronic 
gouty states, and is useful in gout, eczema, or psoriasis. 

There are several sulphur springs in the Pyrenees, of which Eaux- 
Bonnes, Eaux-Chaudes, and Bareges may be specially mentioned. The 
first one lies some 2500 feet above the sea, and the stability of the sul- 



1 4 14 APPENDIX. 

phurous ingredients is said to be a distinguishing feature ; it is power- 
fully diuretic, and is taken more for chronic lung than skin affections. 

Contrexeville is prettily situated in the heart of the Vosges mountains 
about iooo feet above the sea-level. There are five springs, of which 
the Pavilion is the most important and typical. The waters are alkaline, 
with a preponderance of lime salts. They contain also a little iron; they 
are not highly mineralized, so that large quantities must be imbibed. 
They are chiefly used for renal and bladder troubles, especially calculi, 
and for gouty states; and I have found them very useful for pruritus ani, 
due to hepatic disorder as it usually is. 

Ems, Germany. The waters are alkaline, chiefly from bicarbonate of 
soda, and also contain some common salt. The chief springs are the 
Kranchen and Kesselbrunnen, and they are practically identical in com- 
position, but the temperature is 115 F. in the Kesselbrunnen and only 
85 ° at the Kranchen. The first is used mostly for baths, the other for 
drinking. The waters are especially useful in chronic bronchial and 
gastric catarrh, and are very beneficial in some cases of chronic eczema. 
The season is from May to September, July and August being the prin- 
cipal months. The air is bracing and pure, but in summer it is very 
hot. 

Karlsbad, Austria, is a very celebrated spa, picturesquely situated 1,000 
feet above the sea-level. The principal springs are the Sprudel, 165 F., 
the Miihlbrunnen, 126 F., and the Schlossbrunnen, 122 F. They con- 
tain sulphur and bicarbonate of soda, and a moderate quantity of chlorid 
of sodium. They are especially useful in gouty conditions with constipa- 
tion, and are much resorted to for obesity, for sluggish conditions of the 
liver, gall-stones, and diabetes. The season is from April to October, 
but it is very hot in the summer, months, and many, therefore, prefer 
Marienbad, in which the climate is more bracing, as it lies higher, but 
the waters are cold, and nearly twice as strong as those of Karlsbad. 

Kreuznach, in the valley of the Nahe, in Germany, has a warm, dry 
climate, and is noted for its bromo-iodated waters, which are the strongest, 
except Hall, in Austria, but not to be compared to those of Woodhall. 
The principal spring for drinking is the Elisenquelle. The temperature 
is 54. 5° F. The principal constituents are chlorids of sodium, calcium, 
and magnesium, and bromid and iodid of magnesium, but these last 
are in very small quantity. The diseases for which the Kreuznach waters 
are most useful are tertiary S}'philids and strumous diseases. 

La Bourboule, Puy-de-D6me, near Royat, France, is situated at a 
height of 2600 feet above the sea-level. It is noted for being one of the 
strongest arsenical waters known. The composition of the waters and 
their use have been described under " Bottled Waters." The chief spring 
is the Choussy-Perriere. The season is during July and August. It is 
especially useful in psoriasis. 

Levico, in the South Tyrol, near Trient, 4880 feet above the sea-level, 
is not only stronger in arsenic than La Bourboule, but also contains pools 
with some persulphate of iron. There are two springs: the milder con- 
tains eight grains of proto- and persulphate of iron and -^ of a grain of 



APPENDIX. 



415 



arsenic to the pint, while the strong contains thirty-four grains of iron 
salts and -^ of a grain of arsenic per pint. The water is brought down in 
pipes from the mountains behind Levico. 

Loueche, or Leuk, in the canton of Valais, in Switzerland, is 4500 feet 
above the level of the sea. The quantity of salines in it is small, and it 
is chiefly useful as a thermal bath, the principal spring, St. Laurent, be- 
ing 144 F. It is of value especially in a disease like psoriasis, in which 
prolonged soaking is beneficial, while its high altitude gives it claims as 
a sanatorium. 

Marienbad, Bohemia, is about twenty-five miles from Karlsbad, and 
lies 900 feet higher, being at an altitude of 1900 feet; its climate, there- 
fore, is cooler. The waters have the same character as those of Karlsbad, 
but are much stronger both in sulphate and bicarbonate and chlorid of 
soda, and are therefore more distinctly purgative. The chief springs are 
the Kreuzbrunnen and the Ferdinandsbrunnen, the latter being the 
stronger. It is recommended for the same class of cases as Karlsbad, 
when a more decided aperient action and a more bracing climate are 
required. Eruptions of gouty origins are especially suitable. 

Mehadia, or the waters of Hercules, and Pystjan, both in Hungary, 
also have a high reputation, largely earned by the vigorous thermal 
treatment employed, the temperature of the springs at both places being 
very high. 

Plombieres, in the Vosges, is another lofty sanatorium, being 1310 feet 
above the level of the sea, and has a proportionately bracing climate. 
Its waters resemble those of Bath. They contain only a small quantity 
of salts, but the temperature ranges from 66° to 143 ° F., the hottest 
spring in Bath being 117 F. There is, however, an arrangement for 
" continuous baths," and it is, therefore, especially suitable for pemphigus 
and chronic psoriasis. One of its springs contains a minute quantity of 
arseniate of lime. 

Roncegno is about an hour from Trient in the Tyrol. It is situated about 
1600 feet above the sea, and contains in a liter of water .10960 of a 
^ram of arseniate of soda and .11588 of arsenious acid, with small quan- 
tities of cobalt and nickel, 3 grams of oxid of iron, and a little phos- 
phate and sulphate. It is therefore very like Levico, which is not far off. 
The water is brought down from the neighboring Mount Tesobo. The 
-dose is a tablespoonful. 

Royat, in the Puy-de-D6me. is at an altitude of 1400 feet, and its salts 
so nearly approach those of the blood that Gubler calls them "mineral 
lymph." The principal springs are the Cesar, Saint-Mart, and Saint- 
Victor. The first is little more than a pleasant table water, and its 
temperature is 84 F. All have some arseniate of soda; that of Saint- 
Victor is the strongest, both in arsenic and iron, besides containing a 
small quantity of lithia chlorid. They are, therefore, proportionately 
useful in anaemic states, and in gouty and rheumatic eczema and psoriasis. 
The season is from June to September. 

Schinznach, Canton Aargau, Switzerland, are also sulphurous, and are 
much frequented, especially by French people. It lies n 50 feet above 



1416 APPENDIX. 

the sea, in the valley of the Aare, and contains 37.8 cubic centimeters- 
H 2 S and 90 C0 2 per liter. The other constituents are unimportant. 

Schwalbach, in Nassau, is very much like Spa, both in altitude and in 
its waters, with rather more iron, the Stahlbrunnen containing 5^ as 
against 3 of the Pouhon. 

Spa, in Belgium, contains some of the best chalybeate springs, the 
Pouhon being the strongest, containing .375 grains of carbonate of iron 
in sixteen ounces, or 3f grains to the gallon. It has an altitude of 1030 
feet and is beautifully situated in a valley surrounded by pine-clad forests. 

Vals, in the Ardeche, has an altitude of 2475 feet. The chief constitu- 
ent of the springs is bicarbonate of soda, the Magdeleine containing no 
less than 509 grains to the gallon, the two other principal springs, Pre- 
cieuse and Desiree, containing 100 grains less, while the strongest spring 
in Vichy (Celestins) contains 357 grains to the gallon. 

Vichy, in the Allier, at the foot of the Auvergne Mountains, is one of 
the most celebrated alkaline spas. The springs resemble each other in 
the large quantity of bicarbonate of soda they contain, and are largely 
resorted to in rheumatic and gouty states. The Grande-Grille and the 
Celestins are the best known, containing more bicarbonate of soda and 
potash than the others. Gouty eczema is especially likely to be benefited 
by them. 

The most celebrated English spas are: 

Bath, altitude 100 feet, celebrated for its hot springs, the hottest being 
117° F. The mineralization is rather scanty, but the baths are useful in 
psoriasis and rheumatism. 

Buxton is in a valley surrounded by hills, at an altitude of 1000 feet 
above the sea-level; its climate, therefore, is more bracing than that of 
Bath. On the other hand, the temperature of the waters is only 82 F., 
though they are artificially raised to 95 F. The waters are, like those 
of Bath, only slightly mineralized. 

Flitwick has a strong persulphate of iron spring; it has not much 
accommodation for visitors as yet. ( Vide " Bottled Waters.") 

Harrogate does not lie quite as high as Buxton, and is celebrated for 
the number and variety of its springs, of which there are nearly one hun- 
dred. Its sulphur springs are the most celebrated, but it also contains 
chalybeate and saline spas. It is useful in some gouty eczemas, but, like 
all sulphur springs, must be used with caution, and under expert super- 
vision. 

Purton, in Wilts, is a bromo-iodin spring, and useful for strumous 
subjects, but much weaker than the 

Woodhall Spa, in Lincolnshire, which is the strongest bromo-iodin 
spring known, containing 5A- grains of iodin, some of which is free, 
and 82 of bromin, to ten gallons. It contains also a large quantity of 
chlorids. It is especially useful for strumous, syphilitic, and rheumatic 
subjects, and is superior to the more widely known Kreuznach for such 
affections. 

Strathpeffer, in Ross-shire, has lately come into note as a sulphur spring, 
though it also contains a valuable chalybeate spring containing about 



APPENDIX. 



1417 



one-third of a grain of carbonate of iron in the pint, with a large quan- 
tity of carbonic acid. The sulphur springs are some of the strongest 
known, containing more sulphureted hydrogen than any of the Harro- 
gate springs, and more uncombined sulphur than either Harrogate or 
Aix-la-Chapelle, but the old sulphur spring of Harrogate contains nearly 
f jur times as much alkalin sulphid. The climate is mild, and the scenery 
beautiful. The waters are useful for the same class of cases as those of 
Harrogate. 
Other mineral springs of Great Britain are: 

1. Sulphurous : Moffat and Cheltenham. 

2. Saline : Cheltenham, Scarborough, and Leamington. 

3. Chalybeate : Tunbridge, Cheltenham, and Brighton. 

FORMULA. 
BATHS. 

Simple and medicated baths are largely used in the treatment of skin 
diseases. 

1. Simple Vapor and Hot-air (Turkish) Baths find but little employ- 
ment in skin diseases, and would generally be injurious, but simple water 
baths are often used, both for their cleansing and soothing effects. They 
are, however, almost always injurious in eczema. The following shows 
the temperature range of the different varieties: 



Bath. 


Water. 


Vapor. 


Air. 


Cold 

Cool 

Tepid 

"Warm 

Hot 


40 to 65 F. 
65 to 75 F. 
85 to 95 F. 
95 to ioo° F. 
ioo° to no F. 


ioo° to 115 F. 
115 to 140 F. 


IIO° tO I20° 

120 to 180 or more. 



2. Wet Pack. — The wet pack is a modified bath, which is especially 
useful in extensive psoriasis to remove scales and to diminish hyperemia. 
A sheet is wrung out of cold or warm water, and the patient wrapped in 
it, then rolled up in a blanket; after remaining thus for from twenty to 
thirty minutes, or even more, the sheet is removed, the body rubbed dry, 
and then oil or a suitable ointment rubbed in to prevent the skin from 
cracking. 

3. Oil Packing. — In highly inflammatory conditions, such as eczema, or 
pityriasis rubra, or acute inflammatory psoriasis, oil is preferable to water. 
Lint or linen dipped in the best olive oil is bandaged on, or the bandages 
themselves may be dipped in the oil, which must be quite fresh, as the 
least rancidity would produce irritatiom 

4. Medicated Vapor Baths. — These are generally either calomel or 
sulphur. The calomel vapor bath is very valuable in the treatment of 
syphilis; various forms of apparatus are sold for home use. From fifteen 



i 4 i8 APPENDIX. 

to thirty grains of calomel may be volatilized with just sufficient water 
to excite the skin to moderate action. In public baths the preliminary 
steaming is often overdone; the consequence is that patients often faint 
during their use. At University College Hospital I find that the heat 
required to volatalize the calomel is enough to excite sufficient perspiration 
in most people, and since the steaming has been omitted, faintness is not 
induced. For sulphur baths one to two ounces of sublimated sulphur- 
may be used, but this is rarely required for skin diseases, but is useful 
for rheumatic people, and is sometimes used for syphilitics to slightly 
irritate the skin, if there is any doubt about the disease having been 
sufficiently treated. 

Medicated Liquid Baths are used for a variety of diseases, and are of 
divers kinds. The proportions mentioned below are those used at Uni- 
versity College Hospital since they were first started by Tilbury Fox, and 
quoted from his work. They are estimated for a full-length bath with 
thirty gallons of water at a temperature of 90 ° to 95 ° F. The emollient, 
alkaline, and sulphuret of potassium baths are the most commonly pre- 
scribed. 

1. Emollient Baths are made of: (a) Bran 2 to 6 lbs., (b) potato starch 
1 lb., (c) gelatin 1 to 3 lbs., (d) linseed 1 lb., (e) marshmallow 4 lbs., (/) 
size 2 to 4 lbs., to 20 or 30 gallons of water. Use in all erythematous, 
itchy, and scaly diseases. 

2. Alkaline. — (a) Bicarbonate of soda § ij to § x, (b) carbonate of potash 
|ij to |vj, (c) borax \ iij. The bicarbonate of soda maybe used with 

bran liquor, made by infusing a gallon of bran. Use in eczema, psoriasis, 
urticaria, lichen, and prurigo, where there is much local irritation. 

3. Acid. — Nitric or hydrochloric acid § j, or a mixture of nitric acid § j, 
or more, with hydrochloric acid in like quantity to thirty gallons of water. 
Use in chronic lichen and prurigo. The bath should be of porcelain. 

4. Iodin. — Iodin 3 ss. iodid of potassium § ss, with § ij of glycerin, or 
iodin 3j or more, with §j or § ij of liquor potassse to thirty gallons of 
water. Use in scrofulous eruptions, in syphilis, and in squamous diseases. 

5. Bromin. — Twenty drops of bromin with § ij bromid of potassium. 
Use as the iodin. 

6. Sulphuret of Potassium.— § ij to 1 iv to each bath. The balneum 
sulphuris co. of Startin, Sr., is made with § ij of sulphur (precipitated), 

3 j of hyposulphite of soda, and § ss of dilute sulphuric acid, with a pint 
of water, added to the usual thirty gallons of water. Use in itch, in 
chronic eczema, lichen, and psoriasis. 

7. Mercurial. — Bichlorid 3j to 3 iij, with 3j of hydrochloric acid; bin- 
iodid of mercury 3j, with § ij of chlorid of sodium. Use in pityriasis 
rubra and the syphilodermata, especially with ulceration. 

POULTICES. 

Poultices in the time-honored form of bread and linseed meal should 
never be employed, as, unless used most carefully, they are simply culti- 
vating media for germs. When warmth and moisture are required, the 
most unobjectionable forms are boric acid lint soaked in boiled water at 



APPEXDIX. 141 9 

the desired temperature, or Gamgee tissue soaked in carbolic solution 
and covered with some waterproof. For simple moisture, the boric acid 
starch poultice, a favorite application of Jamieson for softening crusts 
and soothing inflammations of the skin, may be recommended. 

Boric Acid Poultices. 
1^ Acidi Borici § ii 

Sig.— Add a teaspoonful of the powder to a tablespoonful of cold water 
starch, mix with a little cold water, then pour in a pint of boiling water, 
and stir till melted; let stand till cold; spread the cold starch thickly on 
pieces of cotton, cover with muslin, and apply to the part, changing the 
poultices every few hours. — Allan Jamieson. 

SOAPS. 

Much has been written of late years on the composition of soaps, both 
for the toilet and for therapeutic formulae. For these purposes, chiefly 
through the advocacy of Unna, an excess of fat, superfatted soaps as 
they are called, have come into vogue. They find their chief use when 
the skin is very thin, as on the face, or when there is a tendency to 
eczema, but are inferior as cleansing agents to a well-made neutral soap. 
The importance of medicated soaps in dermato-therapeutics, as soaps 
are ordinarily used, has been much exaggerated, in my opinion. When 
one considers how little of the medicament is contained in the few grains 
of soap brought into contact with the skin in an ordinary washing, for 
how short a time it remains there, and how carefully it is rinsed and 
wiped off immediately afterward, the therapeutic result can at best be 
but slight and transitory. Of course, if applied with great thoroughness 
and left in contact with the skin for a considerable time, some result may 
be obtained, but complicated with the irritation which the prolonged 
application of soap nearly always produces, and in my opinion the same 
medicaments could have been applied more efficiently in other ways. 
With regard, to the so-called antiseptic soaps still greater fallacies exist. 
Those said to contain perchlorid of mercury, for instance, rarely contain 
that salt, as its composition is generally altered in the manufacture. 
Curzio of Naples made experiments on the effect of this class of soap on 
the growth in cultures of staphylococcus aureus, and his results are 
significant: 

Sublimated one per cent, soft soap was neither aseptic nor antiseptic 
even after twenty-four hours' contact. Sublimated one per cent, hard 
soap required twenty-four hours' continuous contact to have any real 
antiseptic value. Carbolic ten per cent, soap had less aseptic and no 
antiseptic value. Salicylic acid three per cent, and boric acid five per 
cent, are truly aseptic, and are both strongly antiseptic, boric acid being 
the weaker, and they prevent bacterial development in a few minutes. 

Of course, so far as these various soaps, whose name is legion, act at all 
they act in the right direction, but the practitioner should not deceive 
himself as to their real efficacy. The chief makers of this class of soap 



i 4 2 APPENDIX. 

in England are Field, Midgley, Price, and Yardley, and in Germany, 
Beiersdorf , Eichoff, and Stiefel, whose soaps can also be obtained in this 
country 

CAUSTICS, 
i. Arsenic. — Arsenious acid gr. 10, artificial cinnabar 3 ss, rose oint- 
ment 1 ss (Hebra's Cosme's paste); or it may be used as a powder with 
white sugar instead of the ointment. 

2. Calomel 3 ijss, bisulphuret of mercury 3ij, arsenious acid 3j 
(Startin, Sr.). Use in lupus and strumous ulcers, rodent ulcers, and 
syphilis. 

3. Chromic Acid. — A saturated water solution is excellent for warts. 
Gr. 5 to gr. 30 to water \ j for superficial glossitis, syphilitic or otherwise, 
and for syphilitic papilloma of tongue. 

4. Mercury, Acid Nitrate. — B. P. solution; or pure mercury § j, nitric 
acid (sp. gr. 1.4) § ij (Startin, Sr.). Use in lupus, S3 r philis, verruca 
necrogenica, nevus, etc. The addition of 3 j of arsenious acid to Startin's 
formula is sometimes made. 

5. Mercury bicyanid gr. 2 or more to \ j of water. Paint it on in 
acne rosacea, and after two or three minutes wipe it off (Burgess). 

Mercury Red Iodid. — Gr. 10 to gr. 20 to glycerin § ss. Use in lupus 
and syphilis. 

Mercury Perchlorid 3j, collodion 3vj. Lupus and syphilis (Startin, 
Sr.). 

6. Barium. — Barium sulphid 3 i j , zinc oxid and starch each 3 iij. For 
a depilatory: Make into a paste with water, and put on thin coating for 
ten to fifteen minutes; then clean off and apply bland ointment (Duhring); 
or the same proportion of sulphid of sodium may be used; but depila- 
tories are not recommended; they often excite dermatitis, and are no 
better than shaving. 

7. Iodin — Liq. iodi fortis B. P. (1 in 8 of spirit) or a watery solution, 
iodin 3 ss, potassium iodid 3 j, water §j. In glandular enlargements or 
lupus. Coster's paint, or paste, is iodin 3 j or 3 ij to colorless oil of wood 
tar § j; apply with a stiff brush. Excellent for the early stages of ring- 
worm. Morrant Baker prefers creasote, and Aldersmith oil of cade, to 
the ol. picis liquid. Vasogen-iodin ten per cent, does not stain. 

8. Lime, Vienna Paste. — Equal parts of unslaked lime and caustic 
potash; make into a paste with alcohol immediately before using. For 
lupus vulgaris, scrofulodermia, and syphilis. 

9. Potash, Caustic, solid stick, or saturated solution. For same as 
Vienna paste. Weaker solutions gr. 10 to 30 to § j may be painted on, 
and washed off in a few seconds, to clean the surface, in chronic inflam- 
mations, e. g., some cases of sycosis. 

10. Silver Nitrate, solid stick; for lupus vulgrris, to be bored forcibly 
in, so as to plow up the diseased tissue, but it is very painful. Gr. 5 
to gr. 40, in spirit of nitrous ether § j, may be painted on in some cases 
of eczema and pruritus, especially about the anus and genitals, and in 
some other chronic inflammations. 

11. Chlorid of zinc § xvj, powdered opium § jss, hydrochloric acid 3 vj, 



APPENDIX. 142 1 

boiling water to § xx; dissolve. To the solution add 1 dram of wheaten 
flour; mix smoothly in a mortar, and heat over a water bath until of a 
proper consistence (Middlesex formula). Lupus, epithelioma, rodent 
ulcer, etc. 

12. Zinc nitrate one part, bread mass two parts. For same. 

13. Salicylic Acid. — Glycerin § j, salicylic acid enough to make a thick 
cream. To be applied on lint or painted on. For warts, lupus, and 
epidermic thickenings; 3j of carbolic acid or creasote may be added to 
diminish the painfulness of the application. 

14. Zinc and Mercury. — Starch 37 parts, wheat flour 112 parts, per- 
chlorid of mercury 1 part, dry chlorid of zinc no parts, iodol 10 parts, 
croton chloral 10 parts, bromid of camphor 10 parts, crystallized carbolic 
acid 10 parts. Mix them in a mortar in powder, then add gradually 
enough distilled water to form a homogeneous paste of a consistence of 
putty, It will keep a long time. The hands should be wetted when 
applying it, and the paste allowed to remain on from six to twenty-four 
hours (Jules Felix). 

15. Camphor, Carbolic Acid. — Equal parts of camphor and carbolic 
acid are rubbed together in a mortar, and the result is a thick fluid. A 
good superficial caustic for lupus erythematosus and similar conditions. 
(Blackfriars Skin Hospital.) 

LOTIONS. 

STIMULANT AND ANTISEPTIC LOTIONS. 
Mercury. 

1. Perchlorid of mercury gr. 4. diluted nitric acid 3 j, diluted hydro- 
cyanic acid 3 j, glycerin 3 i j , water § viij (Startin, Sr.'s, lotio hydrar- 
gyri bichloridi). Use in syphilitic eruptions, pityriasis versicolor, 
chloasma, freckles, etc. 

2. Perchlorid of mercury gr. 1, distilled water |ij == 1 in 1000 nearly. 
For syphilitic sores. 

3. Perchlorid of mercury gr. 8, distilled water § iv, sulphate of zinc 
and acetate of lead of each 3 ij , alcohol 3 i j . Paint on cautiously. Hardy's 
lotion for freckles. 

4. Perchlorid of mercury gr. 6, diluted acetic acid 3 ij, borax Bij, rose- 
water 1 iv. For freckles (Bulkley). Apply twice a day. 

5. Perchlorid of mercury gr. 2, tincture of benzoin 3 ss, almond emul- 
sion |j. For freckles (Duhring). 

Silver. 

6. Nitrate of silver gr. 2 to 10, water or spirit of nitrous ether § j. For 
eczema, erythemata, and pruritus vulvae et ani. Protargol gr. v. to gr. x, 
distilled water § j. For prurigo, especially on the face. 

Soft Soap. 

7. Oil of cade, soft soap, and alcohol, equal parts, oil of lavender 3 jss 
(Anderson). Similar to Hebra's tinct. sapon. viridis cum pice. Tar may 



1422 APPENDIX. 

be used instead of oil of cade, or less oil of cade employed. For chronic 
eczema, psoriasis of the scalp or knee, etc. 

8. Soft soap, or green soap, in alcohol, equal parts; Hebra's spiritus 
saponatus viridis. To remove scales of psoriasis and seborrhea. I fre- 
quently add thymol gr. xv. to § j. 

8a. Green soft soap alone is very useful for a similar purpose. 

Sulphur. 

9. Precipitated sulphur, alcohol aa § j. For acne (Hebra). 

ga. Sulphur, alcohol, ether, glycerin, carbonate of potassium, of each 
3 ij, rose-water § viij for acne, or without the water, rubbed in for come- 
dones. 

10. Sulphurated potash § ss, lime-water § xvj. For pityriasis versicolor, 
pustular and parasitic diseases. 

11. Sulphurated potash, sulphate of zinc, of each 3 j, rose-water § iv. 
For acne indurata (Bulkley). Duhring speaks highly of the same lotion 
for lupus erythematosus. 

Tar. 

12. Liq. picis carbonis 3j to 3 ij, solution of the subacetate of lead 3j 
to 3 ij, rose-water 3 viij. For eczema and pruritus. 

13. Liq. picis carbonis, diluted 1 to 40 or 1 to 80 with water or spirit, 
may be painted on in chronic eczema. 

14. Liq. picis carbonis 3 1 j , calamin lotion § viij. 

Thymol. 

\<\a. Thymol 3 j, liq. potassse 3 j, glycerin § ss, elderflower water § viij. 
A good hair lotion for dandruff, etc. For other hair lotions see formulae 
43 to 48. 

ASTRINGENT LOTIONS. 

15. Collodion (not the flexible). Acts by mechanical compression. 
Useful in dilated vessels of acne rosacea, in lupus erythematosus, and in 
small superficial capillary nevi. 

16. Hamamelis tincture 1 part to water 4 parts. For dilated capillaries. 

17. Tannic acid gr. 40, French vinegar § ss, water § vijss. For sebor- 
rhea (Neligan), and in hyperidrosis. 

18. Alum gr. 20. sulphate of zinc gr. 10, glycerin 3 j, rose-water § iv. 
For erythema, intertrigo, and eczema (Tilbury Fox). 

19. Boric acid, a saturated solution. For eczema and erythemata. 

ANTI-PRURITIC LOTIONS. 

20. Alkaline solutions and certain antiseptics exercise most influence in 
this respect. 

21. Borax 3 ij, glycerin § ss, water a quart. In urticaria, and as a 
wash for the head in seborrhea. 

22. Borax, carbonate of ammonia, of each 3jss, glycerin §j, diluted 
hydrocyanic acid 3 iij, water §xvj, diluted 1 to 4 times (Startin, Sr.). 
For vesicular and sebaceous diseases. 

23. Carbonate of potash 3 i j . water 1 viij. In the early stages of 
eczema, to allay itching. 



APPENDIX. 1423 

24. Sodium bicarbonate 3j or 3 i j , glycerin 3 jss, elder-flower water 
^ vj. Urticaria, some eczemas, and pruritus. 

25. Liq. picis carbonis 3 ij, water 3 viij. For pruritus, urticaria, and 
eczema, when not too acute. Begin with weaker lotion for eczema. 

26. Carbolic acid, 1 in 60 of water. For pruritus and urticaria. 

27. Terebene §j, water § viij. For pruritus and urticaria. 

28. Sanitas § ij to § iv, water to § viij. For pruritus and urticaria. 

29. Salicylic acid 3 jss, borax 3 j, glycerin 3 j. Mix the acid, borax, and 
glycerin, heat gently until dissolved. This can then be diluted with 
glycerin, alcohol, or water to any extent. 1 j of the first mixture, § j 
alcohol, water to § viij, is a good proportion. Very useful in pruritus 
and urticaria, and does not smell. 

30. Menthol gr. 2 to gr. 10 to alcohol § j. 

31. Solution of subacetate of lead 3 ij to 3 iv, distilled water to § viij. 
For same. 

32. Perchlorid of mercury gr. 2, glycerin § ss, chloroform water to 
1 viij. For same. 

33. Diluted hydrocyanic acid 3 j, corrosive sublimate gr. 1, emulsion of 
almonds or elder-flower water § vj. 

33#. Diluted hydrocyanic acid 3 jss, solution of acetate of ammonia 
§j, infusion of tobacco to § viij. For pruritus ani seu vulvae (Tilbury 
Fox). 

33<£. A similar lotion, but with tinct. digitalis 3iij, and rose-water in- 
stead of tobacco-water (Thompson). 

34. Diluted hydrocyanic acid 3 ij, borax 3 j, rose-water § viij. For 
senile pruritus (Neligan). 

35. Carbolic acid 3 j to 3 ij, liquor potassse 3 j, linseed oil § j. Mix and 
add oil of bergamot q. s. Shake before using (Bronson's anti-pruritic oil). 

36. Potassium cyanid 3 j, water a pint. To be kept in a dark place. 
For pruritus. Use with caution. 

37 Benzoin (compound tincture of), or Friar's balsam. For pruritus 
vulvae (Reeves). To be painted on undiluted, with a camel's-hair brush. 
An excellent plan. 

38. Benzoic acid 3 ij, glycerin §j, water ^ viij. For pruritus and 
urticaria. 

SEDATIVE ASTRINGENT LOTIONS. 

Lead. 

38^. Lead. — Solution of the subacetate mv to ;;zxx, glycerin mxv, 
water |j. For erythema, eczema, excoriations, etc. 

39. Lead with milk. — Solution of the subacetate 3 j, fresh milk §ij. 
Shake well together in a bottle. For eczema and other acute inflamma- 
tions. 

40. Lead, glycerin of subacetate of, B. P. — It may be painted on as it 
is in chronic eczema; in more active cases, it is diluted 1 part to 7 of 
glycerin at first, and the strength gradually increased. It may also be 
diluted with distilled water. 

Liquor picis carbonis is frequently added to the above lotions from mi] 



1424 



APPENDIX. 



to the § j upwards. In eczematons inflammations it should be used tenta- 
tively over a small area at first. 

Zinc. 

41. Calamin lotion. Powdered calamin 3ij, oxid of zinc 3 ss, 
glycerin ;/zxv, rose-water | j. For erythema and eczema, where there is 
little or no discharge, and for most actively hyperemic conditions. The 
addition of tincture of yellow ocher mxv and of tincture of raw umber 
mx, makes a very good imitation of the natural color of the skin, and 
therefore improves it as a face lotion. 

In the skin department of Edinburgh boric acid gr. x, or precipitated, 
sulphur gr. xv, are sometimes added to each § j of the above lotion. 

Bismuth. 

42. Bismuth nitrate gr. viiss, oxid of zinc 3 ss, glycerin mxv, hyd. 
perchlor. gr. £, rose-water § j. For acne rosacea and other hyperemic 
conditions. 

HAIR LOTIONS. 

43. Strong liquid ammonia 3 j, sweet almond oil § j, spirit of rosemary 
3 iv, honey water 3 ij. For baldness (Wilson). 

44. Strong ammonia liniment § ss, castor oil § ss, purified spirit of 
turpentine 3 ss, white precipitate gr. 15. Brush into the scalp with a 
hard brush (Tilbury Fox). 

45. Tincture of cantharides |j, distilled vinegar § jss, glycerin § jss, 
spirit of rosemary §jss, rose-water to | viij. To be sponged into the 
scalp night and morning (Tilbury Fox). 

46 Expressed oil of mace § ss, spirit of wine § viij. To be sponged 
into the scalp (Bateman). 

47. Perchlorid of mercury gr. ij, spirit of wine § ij. Use with a stiff 
brush for seborrhea capitis, but not for more than two weeks at a time. 

48. Vinegar of cantharides |j, glycerin, 3 vj, spirit of rosemary §ij, 
rose-water to § viij. To be sponged in night and morning. 

49. Perchlorid of mercury gr. 2, chlorid of ammonium gr. 10, resorcin 
gr. 20, eau de cologne, § ij, glycerin § ij, rose-water to | viij. For sebor- 
rhea capitis and alopecia. 

50. Sozo-iodolate of soda 3 ij or 3 iij, eau de cologne | ij, glycerin 3 ij, 
rose-water to | viij. For the same. 

Nascent Sulphur. 

51. Hyposulphite of soda 3 iij, eaude cologne § j, distilled or rose-water 
to I viij, for lotion No. 1. Tartaric acid 3 js, distilled water § viij. for 
lotion No. 2. Sponge in first No. 1 and immediately after No. 2. Less 
trouble, but not quite so efficacious, is to shake up equal parts just before 
using. Nascent sulphur, sulphurous acid, and a very little sulphureted 
hydrogen, not enough to be objectionable, are produced (author's form- 
ula). This lotion may also be used for acne vulgaris, and whenever 
sulphur lotions are indicated. The proprietary article sulphaqua is made 
on a similar principle, but has an acid salt instead of tartaric acid. 



APPENDIX. 1425 

SOOTHING AND PROTECTING OINTMENTS. 

1. Spermaceti ointment B. P. 

2. Simple ointment B. P. 
Unguentum paraffin B. P. 

3. Ceratum petrolei (Martindale): vaselin 2 parts, paraffin (135 to 140 ) 
1 part. Melt and stir till cold. 

4. Lanolin 3 vj, olive or almond oil 3 ij. Lanolin alone is too sticky. 
Or lanolin 3 v, liquid paraffin 3 iij. 

Cucumber. 

5. Cucumbers 750 parts. Grate into a pulp, and add rectified spirit 
250 parts. Pass through percolator to make spirit of cucumber. Then 
take lard 125 parts, spermaceti 85 white wax 8, spirit of cucumber 8. 
Melt the fats, put them into a warm mortar, and stir in the liquor. 

Rose Ointment. 

6. Lard |j, white wax 3 i j. Melt, and when half cooled add oil of 
bergamot mix], otto rosar. mi]. Used as a basis with other ingredients. 

Rumex. 

7. Rumex root § xviij, yellow wax § ij, prepared lard §xij. Bruise the 
root, boil for two hours in distilled water, strain and evaporate to | iv. 
Add gradually the lard and wax already melted, and stir the whole 
until cold. 

Any of the above ointments may be used as a menstruum for more 
active remedies. 

SEDATIVE ASTRINGENT OINTMENTS. 

Bismuth. 

8. Bismuth oxid 3 j, oleic acid |viij, white wax |iij. To be made in 
the same way as the oleate of zinc. To form an ointment, equal parts of 
vaselin, lard, or lanolin must be added. McCall Anderson strongly 
advocates this for eczema. Bismuth oleate may also be made by double 
decomposition. 

Boric Acid. 

9. Boric acid 3 ss, benzoated lard § j. It is very important that the 
boric acid should be ground into an impalpable powder; merely rubbing 
in a mortar is insufficient. Excellent in eczema, and as an antiseptic in 
wounds and excoriations. The British Pharmacopeia ointment is nearly 
double this strength and made with a mixture of hard and soft paraffin. 

Lead. 

10. Ung. diachyli (Hebra). — Boil, together olive oil § xv, litharge § iij 
3 vj, to a good consistence, and add 3 ij of oil of lavender. For eczema, 

spread on linen and bind on. A simple way is to melt together equal 
parts of lead plaster and olive oil. These ointments are really oleates of 
lead. 

11. Solution of the subacetate of lead mxv to mxxx, vaselin, lanolin, or 
lard 5j. 

90 



1 4 2 6 APPENDIX. 

12. Lead (carbonate of) gr. 4, glycerin 3 j, simple ointment |j. For 
erythema (Tilbury Fox). 

Zinc. 

13. Unguentum zinci B. P. 

14. Unguentum zinci oleatis B. P. 

Bismuth and lead oleates may be made in a similar way. 

ANTISEPTIC OINTMENTS. 
Iodoform. 

15. Iodoform gr. 3 to gr. 5, vaselin or lard § j. 

16. Iodol gr. 3 to gr. 5 vaselin or lard § j. 

17. Europhen gr. 5 to gr. 10, vaselin or lard § j. 

These ointments are valuable for pustular eczema and impetigo con- 
tagiosa. Mr. Gerrard, formerly Dispenser at University College Hospital,, 
made trial of a large number of plans for rendering the odor of iodoform 
less penetrating and disagreeable. The addition of creolin mv to § j of 
ointment, Jwhere there was not more than 20 grains of iodoform, was one of 
the most successful. An ointment made by macerating freshly ground 
coffee in melted lard, and straining, was also very good, but not readily 
prepared. The powdered oleate of zinc |j, iodoform gr. 5 to gr. 20, 
destroyed much of the odor. Of the various substitutes for iodoform, 
europhen and lore tin are the next most effectual, but nothing entirely 
replaces it as a destroyer of pus cocci, and probably also of tubercle 
bacilli. 

Mercury. 

15. Ammoniated mercury gr. 10, lard |j. Specific for impetigo con- 
tagiosa after the crusts have been removed. 

STIMULATING OINTMENTS. 

Mercury. 

Ung. hydrarg. ammon. B. P., ung. hyd. ox. flav. of the same strength 
as the ung. hyd. ox. rub. of the B. P., ung. hyd. nitrat. and also dil. B. P. 
All these are useful separately or combined, strong or diluted, in chronic 
eczema, seborrhea of scalp, and psoriasis. 

16. Green iodid of mercury gr. 2 to gr. 15, lard § j. For acne (Hardy). 

17. Red iodid of mercury gr. 5 to gr. 20, lard § j. For nodular syphilis, 
lupus, and acne indurata. A powerful preparation, to be used tentatively 
over a small area. Iodo-chlorid of mercury gr. 3 to gr. 10, lard § j. To 
be used in the same way as the iodids. 

Sulphur. 

18. Iodid of sulphur gr. 10 to 3 j. lard §3. For acne. 

19. Powered hypochlorid of sulphur 3 ij, subcarbonate of potash gr. 10,. 
lard I j, oil of bitter almonds mx (Wilson). An excellent remedy for acne, 
but it must always be made with the recently prepared powder of the 
hypochlorid which has not been exposed to the air; if made with the 
liquid it decomposes and irritates. Half or even one-quarter strength is, 
often sufficient. 



APPENDIX. 1427 

Tar and its Allies. 

20. Ung. picis B. P. For psoriasis and chronic eczema, (a) Creasote 
(&) oil of cade, (c) ol. rusci, 3 j or more of either to § j of lard, is much used 
for psoriasis and chronic inflammations. 

21. Tar 3 j, camphor gr. 10, lard § j. In chronic eczema and other in- 
flammations with pruritus. 

Lead. 

22. Iodid of lead gr. 12, chloroform vixx, glycerin 3J, lard § j. For 
eczema and psoriasis. 

Miscellaneous. 

23. Perchlorid of mercury gr. 2 to gr. 5, carbolic acid and olive oil of 
each gr. xx, zinc ointment § j (Unna). For lichen planus. 

LINIMENTS AND OILY PREPARATIONS. 
Carron Oil. 
i. Lime water, olive or linseed oil, of each equal parts. For burns and 
superficial dermatitis. 

Calamin Liniment. 

2. Prepared calamin 3ij, zinc oxid 3 ss, lime-water and olive oil of 
each § ss. Owing to the fact that zinc oxid saponifies olive oil somewhat 
readily, this liniment gradually thickens; should it become too thick it is 
best thinned by addition of olive oil just before using. For eczema and 
acute dermatitis of all kinds. 

At St. Mary's Hospital 3 j of lanolin is added, which makes it a less 
drying application, and is an improvement for some cases. 

In the preceding the parts are wrapped in the oils, not rubbed with 
them. The following are rubbed in: 

Carbolic Oil. 

3. Carbolic acid 1 part, olive oil 19 parts. For pruritic eruptions. 

Thymol Oil. 

4. Thymol gr. 20 to 33, olive oil 3 ix. For seborrhea of the scalp, or 
in acute lichen planus. 

Vasogen-Iodin. 

Vasogen-iodin ten per cent. 3 j, liquid paraffin B.P. § j. For seborrhcea 
capitis, with or without moderate inflammation; also for chilblains. Even 
undiluted the advantage of this and valsol-iodin is that they do not stain 
the skin, while they are readily absorbed. In these and similar prepara- 
tions the iodin is not present in the free state, but usually as the addition- 
product of an unsaturated fatty acid. 

A similar preparation to vasogen-iodin ten per cent, can be prepared 
from the following formula: Iodin 10, strong solution of ammonia 6, oleic 
acid 32, liquid paraffin up to 100. This contains the ammonium salt of 
di-iodostearic acid. 

Turpentine Oil. 

5. Turpentine or oil of silver pine 3 j to 3 vj, olive oil to §j. For 
psoriasis. Oil of cade is a good addition, 3 j to 3 ij to § j. 



1428 APPENDIX. 

6. Perchlorid of mercury gr. 2 to gr. 5, alcohol 3 j, ol. pini sylvest. 
3 vij. For alopecia areata. Should not be kept for more than a week. 

7. Camphor and chloral hydrate equal parts rubbed up together. It 
makes a thick liquid suitable for severe local itching. 

8. (a) Oil of cade, (b) beech or (c) birch oil, 3 j to 3 iv, olive oil to § j. 
For psoriasis, lichen planus, etc. 

APPLICATIONS FOR LUPUS. 

1. R. Zinci oxidi; amyli pulv. aa §£; vaselini albi § ss; hyd. oleatis 
(five per cent.) |j; acidi salicylici gr. 20; ichthyol wxx; ol. lavandulse 
q. s.\ M. Fiat ung. Enough red Armenian bole or raw umber maybe 
added to match the color of the skin. The ointment is well rubbed in 
and covered with potato-starch powder. It is used to produce a certain 
amount of absorption of the lupus tissue (Brooke). 

2. My own formula is — Iodoform gr. 10; creolin m\\\\ adip. benz. §j. 
To be rubbed in at night, and calamin lotion applied in the daytime. 

3. Salicylic acid 3 ss, collodion §3, to be painted on for lupus erythe- 
matosus (Payne). 

4. Resorcin gr. 10 or more, collodion ^j; for similar purposes. The 
weaker preparation should first be used, as resorcin and collodion some- 
times have a distinctly caustic effect. 

5. Benzolin. To be well rubbed in to remove the fatty scales of lupus 
erythematosus; an antiseptic ointment like the iodoform and creolin to be 
rubbed in afterward. 

PASTES AND VARNISHES. 

Pastes may be made hard or soft. 

The hard pastes contain more or less gelatin. One of the most popular 
and generally useful is 

Unna's Gelatin Paste. 

1. Oxid of zinc, gelatin, of each 3 jss, glycerin 3 iij, aq. destill. 3 iv. 
To this, as a basis, gr. 5 or gr. 10 of salicylic acid, resorcin, ichthyol, 
thiol, or other antiseptic may be added. The solid mass must be melted 
by placing the pot in hot water; it is then painted on and dabbed with 
wool, to prevent its sticking to the clothing. It is useful in subacute and 
chronic eczema and similar inflammations, where discharge is absent, or 
very slight. In hot weather, less glycerin and more gelatin may be 
added; but it does not solidify nicely in very hot climates. It is not 
adapted for hairy parts, as its removal is then painful. 

2. This is only one of a series. One contains 3 j of lard and all glyc- 
erin, instead of glycerin and water, with the same amount of zinc and 
gelatin; but the large amount of glycerin is sometimes an objection, as 
the gelatin will not dissolve. 

Soft Pastes. 

These can be applied like ointments, but spread on the skin, leaving a 
coating on it, and absorbing secretion, instead of sealing it up. One of 
the best is 



APPENDIX. 1429 

Lassar's Paste. 

3. Zinc oxid and powdered starch, of each 3 i j , vaselin § ss, salicylic 
acid gr. x. For eczemas and other inflammations, whether dry or moist, 
provided that the discharge is moderate. It should be spread thickly on 
and covered with butter cloth. When changed the old paste can be 
cleaned off with olive oil. In acute inflammation, leave out the salicylic 
acid for a time, or use milder antiseptics, such as thiol or ichthyol. 

Ihle's Paste. 

4. Lanolin, vaselin, zinc oxid, and starch, of each 3 ij, resorcin gr. 10. 

Unna's Paste. 

5. Terra silicea 3 j or 3 ij to the § j of zinc or other ointment answers 
well. According to Griinder, the substitution of ten per cent, of carbon- 
ate of magnesia for some of the other powders increases the absorbing 
power. 

VARNISHES. 

Pick's Varnish (Linimentum Exsiccans). 

6. Tragacanth 5 parts, glycerin 2 parts, distilled water 100 parts. It 
may be made by slowly triturating the powder with the water, or by let- 
ting the tragacanth soak in boiling water. Other ingredients, such as 
antiseptics, may be added. Used for eczematous surfaces, but it is not a 
very comfortable application. 

Elliot's Bassorin Varnish. 

7. Bassorin 48 parts, dextrin 25 parts, glycerin 10 parts, water to make 
100 parts. It is claimed that it keeps better than Pick's formula, which it 
resembles, bassorin being the chief constituent of tragacanth. Used in 
eczema, acne, seborrheic eczema, etc. 

Unna's Ichthyol Varnish. 

8. Ichthyol 40 parts, starch 40 parts, albumin 1 to 1^ parts, water to 100 
parts. Another, without albumin, is ichthyol 25 parts, carbolic acid z\ 
parts, starch 50 parts, water 22| parts. Used for subacute eczema. 

TRAUMATICIN. 

9. This is best made with chloroform, the B. P. solution in bisul- 
phid of carbon is too offensive to be useful. 3 j of pure gutta-percha is 
digested in 3 ix of chloroform, and the bottle shaken daily until a thick 
emulsion is produced. It takes two or three weeks to make properly. 
Chrysarobin and other medicaments can be added as required. 

PLASTERS. 
Emplastrum Fuscum of German Authors. 

1. Camphor 3 ss, black pitch 3vj, yellow wax 3 ix, red oxid of lead 
§ij, olive oil 3 iv. To be melted together until a little burned. For 
boils. 

Emplastrum Hydrargyri (German Formula). 

2. Mercury 3 iv, turpentine 3 ij, yellow wax 3 iij, red plaster § jss. 
Spread upon linen. For acne rosacea, lupus vulgaris and erythematosus. 



1430 



APPENDIX. 



Plaster-Mull Hydrargyri (No. 88 Beiersdorf). 
Mercury 20 parts, carbolic acid 10 parts, perchlorid of mercury 2 parts, 
zinc oxid 10 parts. For boils and carbuncles. 

Paraplast Hydrargyri (No. 255 Beiersdorf). 

Mercury 50 parts, carbolic acid 75 parts. For lupus erythematosus and 
nodular inflammatory infiltrations. 

Salicylic Acid Plaster (Unna). 

3. It is made of thirty-eight per cent, and fifty per cent, of the acid, 
equivalent to 25 or 30 grams of the acid on | of a square meter. It is 
made by Beiersdorf of Hamburg, and is valuable for softening and 
removing corns, callosities, and other epidermic thickenings. 

Salicylic Acid and Creasote. 

4. This is a similar plaster, with the addition of creasote to diminish 
the pain produced when the plaster is applied to lupus vulgaris, for which 
it is a valuable application. It is made of various strengths, from twenty 
per cent, salicylic acid and four per cent, creasote up to forty per cent, of 
each. In both these plasters the salicylic acid is combined with caoutchouc 
and oleate of alumina into a magma, and spread on gutta-percha with a 
muslin backing. The salicylic acid is much more efficacious than when in- 
corporated with the plaster basis, as is usually done. Unna has also used 
lanolin, with a small quantity of caoutchouc, as an excipient. 

Emplastrum Vigo cum Mercuric 

5. Simple plaster 2000 grams, yellow wax 100, resin 100, ammoniacum 
gum 30, bdellium 30, olibanum 30, myrrh 30, saffron 20, mercury 600, 
liquid purified storax 300, larch turpentine 100, and oil of lavender 10. A 
blunderbuss handed down from the Middle Ages, and serviceable still. 
Much used in France for lupus and syphilitic infiltrations. 

Vidal's Emplastrum Rubrum. 

6. Red lead gr. 39, cinnabar gr. 23, diachylon plaster § j. Used for 
lupus, boils, pustular folliculitis, and ecthyma. 

Another formula is red lead 10, cinnabar 6, diachylon plaster 100. 

DUSTING POWDERS. 
Zinc. 

1. Oxid of zinc 1 part, powdered rice or maize, starch, or kaolin 3 
parts. 

2. The same with % part of calamin or \ part of iris root. For excoriated 
surfaces, intertrigo, and eczema. 

Mercury. 

3. Calomel 1 part, and powders 1 or 2, 3 to 6 parts. For erythema of 
buttocks, etc., in congenital syphilis, condylomata, etc. 

Creasote. 

4. Creasote ?;zxvj, kaolin §j (Marshall). For erysipelas, erythema, 
eczema, etc. 



APPENDIX. 143 1 

Tar. 

5. Wood tar 1 part, kaolin 4 parts (Sangster). For the same. 

Boric Acid. 

6. Impalpably powdered boric acid 1 part, and kaolin, rice, starch, or 
white fuller's earth 3 parts. A very good powder for intertrigo. 

Camphor. 

7. Camphor 3 ss, alcohol q. s., oxid of zinc and starch aa § j. Use as a 
powder to allay the burning heat of eczema (Anderson). 

PARASITICIDES. 
Animal Parasiticides. 

1. The ung. sulphuris B. P. For scabies and vegetable parasitic 
eruptions. 

2. Sulphur 3 ss, ammoniated mercury gr. 5, sulphuret of mercury gr. 
10. Mix and add olive oil 3 ij, lard 3 ij, creasote miv = ung. sulphur co. 
of Startin, Sr., for scabies. 

3. Wilson s Formula. — Sulphur § j, carbonate of potash 3 ij, benzoated 
lard § v, oil of camomile 3 ss. Less irritating than B. P. 

4. Helmerictis Formula. — Sulphur §ij, carbonate of potash §j, lard 
Sviij. 

5. Hardy's Formula. — Sulphur § j, carbonate of potash § ss, lard § vj. 

6. Wilkinson's Formula. — Sulphur, tar, and lard, of each § ij; precipi- 
tated chalk §j, sulphid of ammonium 3 ss. For tinea tonsurans and 
scabies. 

7. Hebra's Formula. — Sulphur, oil of beech or oil of cade, of each § iij, 
lard and soft soap, of each § viij, prepared chalk § ij. 

8. Naphthol. — Naphthol 15 parts, prepared chalk 10 parts, lard 100 
parts, soft soap 50 parts. For scabies, psoriasis, etc. (Kaposi). An excel- 
lent remedy; does not irritate like sulphur. Sometimes it is better to 
omit the soft soap. 

9. Cazenave's Solution. — Iodid of sulphur, iodid of potassium, of each 
3 jss, water § xxxij. 

10. Liquor Calcii Sulphidi. — Slaked lime §j, sulphur § v, water § xx. 
Boil for half an hour and filter. Make the quantity up to § xx. For 
scabies and psoriasis. 

11. Vlemingkx's Solution. — Slaked lime |ij, sulphur § iv, water § xx. 
Boil in an iron vessel, and stir with a wooden spatula to a perfect union. 
F"or scabies and acne. 

12. Storax. — Liquid storax § j, lard § ij. Melt and strain. For scabies 
and psoriasis. 

\ia. Ung. staphisagrise B. P. For pediculi corporis. 

13. Carbolic acid solution 1 in 40. Sponge along small portions of hair 
to destroy nits. 

Mercury. 

14. Ung. hydrag. ox. rub. B. P. For pediculi capitis. 

15. Ung. hyd. ammon. B. P. For pediculi capitis. 



1432 APPENDIX. 

16. Perchlorid of mercury gr. 4, acetic acid § ss, water § viij. For the 
nits of pediculi capitis; sponge small portions of the hair with the lotion. 

Vegetable Parasiticides. 

For early stages of ringworm or favus of scalp, blistering applications 
will often arrest the disease. They should not be used for children 
under six. 

17. Coster's Iodin Paint (see Caustics, F. 7). — Paint on firmly, and let 
a crust be formed; remove this, and renew paint. 

18. Hydrag. perchlor. gr. 2 to gr. 4, acetic acid or glacial acetic acid § j. 
Makes a blister (Aldersmith). Use cautiously over a small area at a time, 
as it is a painful application. 

19. Acetum cantharidis B. P. 

20. Glycerin of carbolic acid B. P., or even 1 in 3. 

Strong Applications for Later Stage of Ringworm. 

These also should not be used in strumous children or those under six 
years of age, and at all times with caution and over a limited area at first. 

21. Nitrate of mercury ointment, sulphur ointment, and carbolic acid 
in equal proportions, either diluted or not, as required. A good, but 
dirty preparation. It should be made without heat, and the carbolic 
acid thoroughly incorporated with the sulphur ointment before the citrine 
ointment is added, and this last should be free from excess of nitric acid. 
(Aldersmith). 

22. Croton Oil. — As a liniment, croton oil 1 part, olive oil 3 parts, cau- 
tiously increased. Use cautiously over about \ in. square at a time. 
The pure oil may be used to individual hairs, a minute drop being intro- 
duced into the hair follicles with a needle. 

Boric Acid. 

23. Boric Acid. — Boric acid gr. 20 or q. s., sulphuric ether 3 j, rectified 
spirit 1 j. To make a clear saturated solution. To be dabbed on with a 
sponge, so as to soak into the scalp (Cavafy). 

Chrysarobin. 

24. Chrysarobin gr. 10 to gr. 20, benzole 1 j. 

25. Chrysarobin gr. 7, chloroform § j (Aldersmith). For same purpose 
as boric acid solution. 

26. Chrysarobin 3 ss to 3 ij, lanolin c. oleo § j. For ringworm of scalp, 
fork, and axillse, and tropical forms; also valuable in alopecia areata. 
Patients should be warned of the possibility of its producing erythema. 

27. Goa powder, which contains eighty per cent, chrysarobin, may be 
substituted. 

Mercury. 

28. Perchlorid of mercury gr. 1 togr. 3 in alcohol § j. 

29. Perchlorid of mercury gr. 2 to gr. 5, q. s., in lard § j. 

30. (a) The yellow oxid, (b) the ammonio-chlorid, and (c) the nitrate 
of mercury, are all parasiticides, but rather mild ones, and adapted for 
tinea circinata, (a) oleate of mercury four to twenty per cent, with or 
without lanolin, a very good preparation. 



APPENDIX. 1433 

Salicylic Acid. 

31. Salicylic acid gr. 40 to gr. 60, alcohol 3 vj, ether 3 ij. Or: 

32. As an ointment in the same proportion to § j of lanolin c. oleo. I 
have also used Unna's plaster with some benefit, and the glycerin cream 
over a limited area. 

2,2a. Salicylic acid gr. 10, collodion |j. Paint on for a week, then 
remove forcibly, one blade of epilation forceps being inserted beneath the 
collodion, then the pellicle pulled off; it brings a large portion of the dis- 
eased hair stumps away; but as the removal is rather painful, the treat- 
ment is not suited for the very young. When the scalp is clear, renew 
the application. 

Thymol. 

33. Thymol 3 ss to 3 ij, lanolin § ij. Thymol and menthol 3 ss to § j of 
chloroform or spirit and ether (Malcolm Morris). Thymol may also be 
combined with copper oleate 3 j; thymol 3 j, sulphur 3 j, lanolin and lard 
toij. 

Copper Oleate. 

34. Pure oleate of copper 3 ss to 3 ij: lanolin c. oleo % j. Valuable for 
tinea tonsurans. It is especially valuable at an early stage, as it renders 
wholesale epilation comparatively painless after it has been rubbed in for 
a few days. 

May be combined in equal proportions with mercuric oleate. 

35. Sulphurous Acid. — Pure, or with an equal quantity of water. For 
tinea versicolor. 

36. Hyposulphite of sodium 3 vj, water § viij. For tinea versicolor and 
tinea cruris. 

All the sulphur preparations are vegetable, as well as animal parasiti- 
cides. 

37. Borax 3 iv, glycerin 3 ij, water § vj. For tinea versicolor. Also 
glycerin of borax B. P. for lichen circinatus, tinea versicolor, and ery- 
thrasma. 

Resorcin. 

38. Resorcin 3 j, lanolin 3 j, and liquid paraffin 3 iij. 
In some cases oleate of copper 3 j is a useful addition. 

Turpentine. 

39. Perchlorid of mercury gr. 2, alcohol 3 j, turpentine § vij. 

40. The ol. pini sylvestris is less unpleasant than ordinary turpentine, 
and 3 j of oil of lavender may be added. For tinea tonsurans and alopecia 
areata. 

PILLS. 
Laxative. 

1. Aqueous extract of aloes gr. 1, extract of belladonna and extract of 
nux vomica, of each gr. \. Mix. Take one every night. For chronic 
constipation. 

2. Aloin gr. A, strychnia gr. ^, extract of belladonna leaves gr. \. For 
the same (Schieffelin). 



1434 APPENDIX. 

Arsenic. 

3. Arsenious acid gr. 1, extract of hop 3j. Mix, and divide into 30 
pills. Take one three times a day after meals. For psoriasis, etc. 

4. Asiatic Pills. — Arsenious acid gr. 66, powdered black pepper 3 ix, 
gum-arabic and water q. s. Divide into 800 pills; each pill contains .0825, 
or T x ¥ of a grain of arsenious acid. This formula is much used on the 
Continent, and Hebra gave three pills once a day immediately before 
dinner, increasing the number according to the tolerance of the patient 
and the obstinacy of the disease. It is, however, much safer to begin 
with one after meals, as they are less likely to derange the diges- 
tion. 

5. Arsenate of soda gr. 1, water sufficient to dissolve, powdered guaia- 
cum 3 ss, oxysulphuret of mercury gr. 20, mucilage q. s. Divide into 24 
pills. One three times a day (Wilson). 

6. Arsenate of soda gr. 2, extract of hop gr. 20, sulphate of iron gr. 20, 
extract of nux vomica gr. 3. Divide into 24 pills. 

7. Arsenate of iron gr. 3, extract of hop 3 j, powdered marshmallow 3 ss, 
orange-flower water q. s. Divide into 48 pills; each contains^ of agrain 
of arsenate of iron (Biett). 

8. Iodid of arsenium gr. 2, manna gr. 40, mucilage q. s. Make 40 
pills. 

It is very questionable, considering the smallness of the dose, whether 
there is any material difference in the action of these different salts of 
arsenic, except so far as they differ in the relative quantity of arsenic 
they contain. It is always safer to give the arsenic after meals, and 
where there is irritability of stomach from its use, opium may be com- 
bined with it. 

Phosphorus. 

9. Phosphorus is sometimes useful in psoriasis as a nervine tonic, and 
according to Burgess, in lupus. It is, however, so difficult to make up 
into pills, that unless the druggist is skillful either an inert substance or 
unequal dosage is produced. It is better to order them, therefore, in the 
ready-made form of coated pills, which are now furnished by so many 
reliable English and American houses. 

POWDERS. 

1. Precipitated sulphur gr. 10 to gr. 60, acid tartrate of potassium gr. 
10 to gr. 20, powdered ginger gr. 2, white sugar gr. 20. Take in milk 
night and morning for hyperidrosis of hands and feet, etc. 

Pulvis Rhei cum Soda. 

2. Powdered rhubarb gr. 1^, dried bicarbonate of soda gr. 2, powdered 
ginger gr. ^. (East London Hospital for Children.) 

Pulv. Rhei Hydrargyrata. 

3. Pulv. rhei c. soda gr. 4, hyd. c. cret. gr. 1. (East London Hospital 
for Children.) 

Either is very useful as an alterative powder for children. 



APPENDIX. 1435 

MIXTURES. 
Aperient. 

1. Magnesium carbonate gr. 15, magnesium sulphate 3j, peppermint 
water 3 j. 

2. The same, with the addition of the wine of colchicum mxv in gouty- 
states. 

3. Magnesium sulphate, sodium sulphate, each 3j, tincture of bella- 
donna ;;/v, syrup of ginger 3 ss, infusion of cloves to § j. For scybala. 

4. Magnesium sulphate 3 j, compound tincture of cardamoms mxx, com- 
pound infusion of roses § j. 

5. Sodium bicarbonate gr. 10, pulv. rhei gr. 4, tincture of hyoscyamus 
mx, dill water § j. A mild aperient for dyspeptic conditions. 

6. Cascara sagrada liquid extract 7/zxv, tincture of belladonna mv, 
infusion of cloves 1 j. 

Diuretic. 

7. Acetate of potassium gr. 15, bicarbonate of potassium 10, spirit of 
juniper mxv, infusion of broom § j. Before meals, well diluted. 

For Dyspepsia. 

8. Sodium bicarbonate gr. 10 to gr. 15, sal-volatile mx, compound infu- 
sion of gentian § j. Half an hour before meals. 

9. Sodium bicarbonate gr. 10, tincture of nux vomica 7/zv, glycerin ;/zxv, 
compound infusion of orange peel § j. Ten or fifteen drops of the cascara 
sagrada liquid extract is often a useful addition. To be taken half an 
hour before meals. 

10. Bismuth carbonate gr. 10, sodium bicarbonate gr. 10, compound 
powder of tragacanth gr. 10, infusion of orange §j, tincture of nux 
vomica mv. 

For Atonic Dyspepsia and as a Tonic. 

11. Diluted nitro-hydrochloric acid ;;/x to ;/zxv, glycerin mxx, tincture 
of cascarilla 3 ss, water § j. The same with sulphate of magnesium 3 j is 
often useful in bleeding piles. 

12. Diluted phosphoric acid mxv, tincture of nux nomica mv, glycerin 
mxx, water to § j. 

Ferruginous. 

13. Citrate of iron and ammonium gr. 10, citrate of potassium gr. 10, 
syrup of tolu mxx, infusion of calumba § j. 

14. Citrate of iron and quinine gr. 5, syr. aurant mxv, water § j. 

15. Mist, ferri comp. B. P. 

16. Sulphate of iron gr. 2, sulphate of magnesium 3 jss, diluted sul- 
phuric acid mxv, infusion of quassia to § j. For acne vulgaris, eczema, 
etc. " Startin's [the elder] mixture." 

17. Syrup of the iodid of iron B. P. 3 ss to 3 j, in water after meals. The 
water must be added only just before it is taken. For lupus and stru- 
mous affections generally. 

All iron mixtures should be taken immediately. 



1436 APPENDIX. 

Arsenical. 

18. Fowler's solution mi] to mx, tincture of hop 3 ss, water §j. For 
psoriasis and other dry scaly eruptions, and for recurring vaso-motor dis- 
turbances, such as urticaria, pemphigus, hydroa. 

19. Fowler's solution miv, steel wine 3 j, simple syrup mxx, water § j. 

20. Fowler's solution my, citrate of iron and ammonium gr. 5, infusion 
of quassia § j. 

21. The solution of arsenate of soda may be substituted in any of the 
above for Fowler's solution, but it contains little more than half the 
amount of arsenic present in the latter. 

22. Hydrochloric solution of arsenic wiv, diluted hydrochloric acid 
myij, tincture of perchlorid of iron wx to ;;/xx, water § j. 

All these arsenical mixtures should be given well diluted immediately 
after meals. 

Mercurial. 

23. Perchlorid of mercury gr. -^ to |, diluted hydrochloric acid wx, 
infusion of quassia § j. 

24. Perchlorid of mercury gr. T V iodid of potassium gr. 5, infusion of 
calumba §j, sal-volatile mxv. For syphilis, especially in the tertiary 
stage. 

25. Liquor arsenii et hydrargyri iodidi, or Donovan's solution, dose 
//zv, to wxxx, with a bitter infusion § j, contains one per cent, each of the 
iodids of arsenic and mercury. It is useful in lichen planus and many 
chronic scaly eruptions, as well as syphilids. 

26. Bicyanid of mercury gr. j 1 ^, infusion of quassia § j. 

Donovan's solution is used in the tertiary stage of syphilis. Many use 
the other mixtures quite early; for my own part, I use them chiefly in the 
later secondary and tertiary periods. 

27. Decocta Zittmanni. Strong. — R. radicis sarsae concisae § xij, aquae 
fontanse libras lxxii. — Digest for twenty-four hours, then add tied up in a 
piece of linen: sacchari albi, aluminis aa 3 vi, calomelanos 3 iv, antimonii 
sulphurati 3 j. Simmer down to 12 quarts; toward the close of the sim- 
mering add: seminum anisi contus. , seminum fceniculi contus., aa § ss, 
foliorum sennse 1 iij, radicis glycyrrhizte concisae § jss. Press and strain; 
after standing until cool, decant the clear liquid and bottle 12 quarts. 

Weak. — To the dregs of the strong decoction add: radicis sarsae concisae 
§ vj, aquae fontanae libras lxxii. Simmer down to 12 quarts, and toward 
the close of the simmering add: Corticis fructus citri contusi, cardamo- 
mum minorum contus. , radicis glycyrrhizae concisae, aa % iij. Squeeze and 
strain, and after standing until cool, decant the clear liquid and bottle 12 
quarts. One bottle of the stronger decoction is to be taken warm before 
twelve o'clock in the day, and one bottle of the weaker decoction cold be- 
tween twelve o'clock and bedtime. It has been suggested that the mer- 
curial and antimonial salts contained in the linen bag are useless, as 
undergoing no solution in the liquid, but Wilson fancied that the remedy 
answered better when prepared in accordance with the old formula than 
in a mutilated form. The treatment should be commenced with an active 
purge of calomel (gr. 4) and colocynth (gr. 8) in two pills; if the action of 



APPENDIX. 



1437 



the bowels be sluggish, the purgative should be repeated in the evening 
of the fourth day (Wilson). 

Alfred Cooper and Bouchardt say hydrag. bisulph. rub. is the ingredi- 
ent instead of antimonii sulphurati, and Cooper gives the following direc- 
tions: " The patient is kept in a room at 80 F. The diet consists of: 
Breakfast — boiled egg or bacon, tea (no sugar or spices); Lunch — butch- 
er's meat and vegetables, no fruit; Dinner — soup, fish, poultry. The 
evening before the treatment one or two of the pills are taken, and for 
the next four days at 9 a. m., 10 a. m., ii a. m., and 12 noon, half a pint of 
the strong decoction drunk very hot, and 3 p. m., 5 p. m., and 6 p. m., half a 
pint of the weak decoction cold. The patient is kept in bed except for 
one hour every evening. On the fifth day the patient is allowed to get 
up, he may have a hot bath and dress, and is allowed, if he asks for it, a 
little brandy or whisky and soda. In the evening, one or two pills are 
again administered, the patient starting the decoctions the next day as 
before. So the treatment goes on until the fifteenth day, when it is 
discontinued." 

He states that it succeeds in many cases in which the ordinary treat- 
ment has failed. Ulcers which were spreading in spite of ordinary 
syphilitic treatment heal up under " Zittmann." Also in chronic syphilis 
affecting the nervous system. 

27a. Van Swieten's Spiritus Anti-venereus. — Corrosive sublimate 3 ss, 
spirit of wine 3 lxxx. Dissolve. 

The French formula is: Perchlorid of mercury 1 gram, alcohol (ninety 
per cent.) 100 grams, distilled water 900 grams. A tablespoonful contains 
16 milligrams of the salt. 

Miscellaneous Mixtures. 

28. Oil of turpentine wx to ;«xxx, oil of lemon mij, mucilage of acacia 
1 ss, water § ss. Take immediately after meals, three times a day. The 

last dose not to be later than 6 p. m., and during the treatment at least a 
quart of barley-water to be drunk in the course of twenty-four hours. 
For psoriasis, eczema, and hyperemia of the skin (Author). 

29. Antimonial wine ?n\\] to ;«v, water |j. For eczema (Malcolm 
Morris). 

30. Tincture of guaiacum ;;zxl, tincture of aconite mi], camphor water 
3* ss. For chronic skin diseases, especially with rheumatic taint (Tilbury 
Fox). 

31. Tincture of iodid m\\] tomv, in water after meals. For lupus vul- 
garis (Liveing). He also gives it combined with an equal quantity of 
Fowler's solution. 

32. Tincture of cannabis indica mx to ;«xxx, compound powder of 
tragacanth gr. 10, water § j. For pruritus and prurigo (Bulkley). 

FOR SUBCUTANEOUS OR INTRAMUSCULAR INJECTIONS. 

Mercurial Intramuscular Injections. 

1. Lang's Gray Oil (Oleum cinereum). — Mercury and lanolin, of each 
3 parts, olive oil 4 parts = thirty per cent. During the first week the 



1438 APPENDIX. 

patient receives injections in two places in the back of .1 to .2 c.c. After 
from two to three days the same quantity is injected in the same place, 
and every week .1 c.c. is injected throughout the whole course. A fifty 
per cent, oil is also used, the dose being .05 c.c. 

2. J. Alt halts' Cream. — One part mercury is to be incorporated into 
4 parts each of lanolin and two per cent, carbolized olive oil. 

3. Yellow Oxid of Mercury (Watraszewski's). — Yellow oxid of mer- 
cury 1 gram, gum arabic *■ of a gram, distilled water 30 grams. Shake 
and inject a Pravaz syringeful deep into the tissues once a week, i. e., 4 
centigrams, or f of a grain. 

4. Perchlorid of Mercury (Astley Bloxam). — Perchlorid of mercury 
6 grains, distilled water § j. Inject 20 drops (^ of a grain) once a week 
deep into the gluteal muscles. Very good, but very painful. 

5. Gliitin-peptoiie-sublimate contains twenty-five per cent, of mercuric 
chlorid. It is prepared in a one per cent, solution, and a Pravaz syringe- 
ful (= 1 centigram, or \ of a grain) is injected. 

6. Succinimid of Mercury. — One per cent, solution. Dose, a Pravaz 
syringeful, or \ to \ of a grain (Vollert). Selenew thinks it is equally 
efficacious with the yellow oxid, and superior to the alanate, the salicy- 
late, or the gray oil. Calomel injections are more dangerous. 

7. Schwimmer's Formula for Hypodermic Injection in Syphilis. — Sozo- 
iodolate of mercury gr. 12, iodid of potassium gr. 25, distilled water § ijss. 
Inject 1 Pravaz syringeful a week, equal to an inunction of 3 v ung. hyd, 

8. The formula I use is sozoiodolate of mercury 3 grains, and iodid 
of soda 6 grains, rubbed up and dissolved in 4 drams of boiled distilled 
water. Twenty minims — \ grain is injected into the buttock once a 
week. This salt is much less painful than the perchlorid. 

9. Salicylate of Mercury (Eich). — Hydrarg. salicylatis 3 i, paraffin 
oil 3 ix. Shake well before using, and inject a Pravaz syringeful into 
the buttocks once a week. Said not to be painful, but Boucy found 
it too painful to use; and there is one fatal case on record. 

10. Benzoate of Mercury (Stoukovenkoff). — Benzoate of mercury .30 
grams, chlorid of sodium .10 grams, chlorhydrate of cocain .15 grams, 
distilled water 40 grams. From half to a whole Pravaz syringeful (15 m.) 
is injected daily = 1 centigram of the salt. Thirty to 40 injections for an 
average case. 

11. Double Hyposulphite of Mercury and Potassium (Dreser and 
Camerey). — .25 of a gram is dissolved in 10 grams of distilled water. 
From \ to a whole Pravaz syringeful is injected, which is a dose corre- 
sponding to -jL to \ of a grain of corrosive sublimate. The double salt 
contains 31.4 per cent, of mercury. It is said to be not more painful than 
a morphia injection. 

For Intravenous Injections. 

1. Perchlorid of Mercury. Baccellfs Solution. — Perchlorid of mer- 
cury 1 grain, chlorid of sodium 3 grains, distilled water 1000 grains. Fil- 
ter and warm slightly before injection. Inject 15 minims, following the 
directions in the text. Note the objections to the treatment 



APPENDIX. 1439 

2. Cyanid of Mercury (Chopping). — A one per cent, solution in distilled 
water. Twenty m. is injected daily. 

Thiosinamin. 

This drug is obtained from the volatile oil of mustard, and is chemi- 
cally allyl-sulpho-carbamid. It was introduced by Hans Hebra as an in- 
jection method for lupus vulgaris, but is not now used for this, but is very 
valuable for keloids and hypertrophic scars. It occurs in white crystals. 
The original solution was alcoholic, but this gives much pain, and the 
following is now used: Thiosinamin 8 grains, glycerin 20 minims, water 
up to no minims. Dissolve with gentle heat. Up to 20 minims in 3 or 4 
injections; can be introduced beneath the tumor once or twice a week. 

Cacodylate of Sodium. 

This organic compound of arsenic, which has been described in the 
General Section on Therapeutics, may be used in sarcomata and similar 
serious cases, but unless further experience proves to be less dangerous 
than it appears likely to be, should not be used for cases in which arsenic 
is usually suitable. It is sold in sterilized solutions in tubes containing 
one grain of the salt in 15 minims, which is the dose recommended. 

Another similar compound is arrhenal (disodium methyl-arsenate), 
which is recommended by Gautier, as it has not the unpleasant effects of 
the cacodylate when administered by the rnouth. The hypodermic dose 
is 5 to 10 centigrams, or \ to 1^ grains. Squire supplies an injection of \ 
grain in 10 minims, as well as \ grain globules for administration by the 
mouth. 

Coley's Fluid. 

The fluid is prepared by growing the Streptococcus Erysipelatis and 
the Bacillus Prodigiosus in the same flask for a certain number of days. 
The resulting culture is then sterilized by heat, filtered through steril- 
ized filtering paper, and a small quantity of carbolic acid added, so that 
the resulting fluid contains 0.5 per cent, of carbolic acid. 

The fluid is injected hypodermically with all antiseptic precautions, in 
the neighborhood of the tumor. It is, however, necessary to use small 
doses at first, that is, not more than half a minim, as severe fever often 
follows larger doses. 

This fluid has been recommended for malignant tumors. The success, 
however, has only been very meager, and as far as mycosis fungoides is 
concerned quite failed in one of my cases. 



INDEX. 



Abode as a cause of skin disease, 51 
Abscess caused by quinine, 505 
Acanthia lectularia, 1386 
Acanthoma, 107Q 

Acanthoma adenoides cysticum, 982 
Acanthosis nigricans, 597 
Acarus folliculorum, 1133, 1369 
" scabiei, 1362 
" vanillse, 1369 
Acetanilid cyanosis, 470 
Achorion Schoenleinii, 1274 

" examination of, 
1408 
Achromia, 675 

" congenital, 673 
Acne, 1 136 

adolescentium, 1137 

agminata, 11 64 

albida, 1129 

atrophica, 11 55 

cachecticorum, 1138 

chlorin, 1139, note. 

classification, 1136 

disseminata, 1137 

erythematosa, 1147 

excoriated, 1161 

frontalis, 11 55 

generalis, 1138 

hypertrophica, 1148 

indurata, 11 37 

keloid, 937, 1243 

keratosa, 1160 

mentagra, 1236 

necrotica, 11 55 

necrotisans et exulcerans ser- 
piginosa nasi, 1163 

paraffin, 11 39 

punctata, 1137 

pustulosa, 1 137 

rodens, 1155 

f Etiology, 1 1 50 ") 



rosa- 
cea 



91 



j Pathology, nsr 
} Diagnosis, 1152 
[Treatment, 1153 J 



MH7 



vul- 
garis 



^ ii37 



161 



Acne scofulosorum, 11 59 
sebacea, n 10 
simplex, 1137 
tar, 1139, 1141 
telangiectodes, 1164 
urticata, 1161 
varioliformis, 1155 

" of the extremities, 

1167 
f Varieties, H37, 
I 1138 

J Etiology, 1139 
j Pathology, 1140 
j Diagnosis, 1141 
[_ Treatment, 1142 J 
Acne, 1136 

cheloidique, 1243 
chlorique, note, 11 39 
cornee, 610 
excoriee des jeunes filles, 1 

note 
keratique, 1163 
rosee, 1147 
sebacee, 11 10 

" huileuse, 11 10 
" seche, 11 13 
" cornee, 6to, 1163 
varioliforme de Bazin, 729, 1155 
Acneiform eruption in lupus erythe- 
matosus of scalp, 822 
" nevus, 1134 

Acnitis, 1164 
Acrochordon, 944 
Acrodermatitis perstans, 236 

pustulosa hiemalis, 350, 
1169 
Acrodermites continues, 236 
Acrodynia, 154 
Actinomyces, 1340, 1343 

" staining of. 1407 

Actinomycosis of the skin, 1339 
Acute circumscribed edema, 157 
Adamson's method of staining ring- 
worm fungi, 1409 
Addison's disease, 657 
keloid, 628 



1441 






1442 



INDEX. 



Aden ulcers, 544 

Adenoid epithelioma of the sweat 

glands, 978 
Adenoma of sweat glands, 982 

" sebaceum, 986 

'• " fibromata in, 987 

Age as a cause of skin disease, 55 
Agminated pustular folliculitis, 1290, 

i2lji, note. 
Ainhum, 710 
Albinism, 673 
Albinismus, 673 
Alcohol in the treatment of skin 

eruptions, 74 
Aleppo boil, 1069 
Algidite progressive, 640 
Alibert's keloid, 933 
Alopecia, 1200 

" Etiology of, 1202, 1203 
f Varieties, 1209 "] 

«' are ! Etiolo gy» I2I 9 

ata ^ Pathol °gy> I22 3 \ 1209 
I Diagnosis, 1227 
[Treatment, 1229 J 

" " band form of, 1214 

" " endemics of, 1220, 1221 

" cicatricial, 1232 

" cicatrisata, 1232 

" circumscripta, 1209, 1232 

" congenital, 1200 

" idiopathic premature, 1202 

" keratosic, 1203 

" neuritica, 1211 

( universalis, \ 

" neurotica-} 1210 >• 1210 

r localis, 121 1 ) 

" orbicularis, 1232 

** parasitica, 1210 

" pityrodes, 11 14 

" ' " universalis, 11 14 

" seborrhoica, 1204 

" " circinata, 12 18 

" senile, 1201 

" simplex, 1202 

" symptomatic premature, 1202 

" universalis, 12 10 

" varieties of, 1200 
Alopecie cicatricielle, 1232 
Alphos, 354 
Amboyna button, 1057 
Anesthesia, 726 

dolorosa, 726 
Analgesic paralysis with whitlow, 

707 
Analysis of fifteen thousand cases of 

skin disease, 1399 
Anatomical tubercle, 799 
Annamite ulcer, 1069 
Angiokeratoma, 574, 613 
Angioma pigmentosum atrophicum, 
681 



Angioma serpiginosum, 970 

Angiome cystique, 974 

Angiomyoma, 959 

Ankylostoma larvae, 1397 

Anidrosis, 1100 

Anilin dermatitis, 463 

Animal parasites of the skin, 1357 

" " classifi- 

cation of, 

1357 
" poisons, 507 
Anomalies of pigmentation, 655 

" pathology of, 

6 55 
Anthracoid eruptions, drugs causing, 

505 
Anthrax, 260, 513 

" bacillus, staining of, 1407 
Antifebrin, eruptions from, 470 
Antimony in the treatment of skin 

eruptions, 79 
Antipyrin, eruptions from, 470 

in the treatment of skin 
eruptions, 79 
Antisepticism in the local treatment 

of skin diseases, 84 
Antitoxin rashes, 503 
Appendages, diseases of the, 1087 
Aperients in the treatment of skin 

diseases, 82 
Appendix, 1399 
Area Celsi, 1209 
Argyria, 671 

" -like pigmentation from sar- 
coma, 668 
Arnica dermatitis, 461 
Arsenic, eruptions from, 472, 672 
" in the treatment of skin dis- 
eases, 74 
Arsenical cancer, 475 
" dermatitis, 465 
" keratosis, 474, 589 
" pigmentation, 474 
Aspergillus nigrescens, favus-like 

lesion due to, 1278 
Atheroma, 1124 

Atheromatous cysts, multiple, 11 26 
Atrophia cutis, 680 

" senilis, 697 
" universalis, 692 
Atrophise, 680 
Atrophodermia, 680 

albida, 691 
neuritica, 703 
pigmentosa, 681 
" senilis, 697 

•' striata et maculata, 

698 
table of, 680 
Atrophy, classification of, 680 
degenerative, 680 



IXDEX. 



1443 



Atrophy, idiopathic congenital, 694 
" " cutaneous, uni- 

lateral, 693 
" " diffuse, 693 

" " general, 629 

" " unilateral, of 

face, 637, 693 
" of hair, 1187 

" " pigment, 1193 

" quantitative, 680 

symptomatic, 681, 696 
" " degenerative, 

697 
unilateral of the face, 637 
Aurantia eruption, 465 
Aussatz, der, 900 
Autographism, 159 



B 



Bacchia rosacea, 1147 

Bacilli, staining of, 1406 

Bacillus anthracis, staining of, 1407 

" leprae, staining of, 1408 

" mallei, 512 

" " examination of, 1408 

" pyocyaneus, diseases with, 

539 
" tuberculosis, diseases due 

to, 760, 761 
" tuberculosis, staining of, 

1410 
Bacteria as pathogenic agents, 64 
Bactericides in the treatment of skin 

eruptions, 89 
Balanitis, persistent, 287 
Bald tinea tonsurans, 1284 
Bandages in the treatment of skin 
eruptions. 85 
Martin's, 85 
Barbadoes leg, 645 
Barber's itch, 131 5 
Barcoo rot, 1076 
Barkoo, 1076 
Bartfinne, 1236 

parasitare, 1315 
Bassorin varnish, 92 
Bathing drawers area, 47 
Baths, formula for, 1417 

in the treatment of skin erup- 
tions, 84 
Bazin's disease, 811 
Beaded hair, 1191 
Beerschwamm, 1057 
Belladonna eruptions, 475 
Benzoate of soda eruption. 476 
Bichromate of potash dermatitis, 464 
Bilharzia ova in skin, 1397 
Biscara button, 1069 
Biskra button, 1069 
Black disease of the Garo Hills, 668 



Black dot ringworm, 1286 
Blanching of hair, 1193 
Blaschen, 37 
Blaschenflechte, 265 
Blasen, 38 
Blasenausschlag, 295 
Blastomycetes, 1353 
Blastomvcosis, 1350 
Blebs, 38 

Bleeding stigmata, 1098 
Blepharitis trichophytica, 1320 
Bloody sweat, 1098 
Blue pigmentation, 668 
Blutfleckenkrankheit, 548 
Blutgeschwiir, 254 
Boil, 254 

" Oriental, 1069 
Boils, drugs causing, 505 
Borax eruptions, 477 
Boric acid eruptions, 476 
Borken, 41 
Bot-fly, 1387 
Botryomycosis hominis, 108 1 

after vaccination, 526 
Bowditch Island ringworm, 1323 
Bran dsch war, 260 
Bromid, acne, 477 

eruptions, 477 
Bromidrosis, 1092 
Bromin eruptions, 477 
Bromoform eruption, 480 
Bronze diabetes, 667 
Bucnemia tropica, 645 
Bug, 1386 
Bug-bites, 1386 
Bullae, congenital predisposition to, 

293 

definition of, 38 
" from cerebro-spinal affec- 
tions, 296 
" hemorrhagic, 242 
Bulles, 38 
Bullous eruptions, 287 

" " drugs causing, 504 

Button scurvy of Ireland, 1035 



C 



Cacodylate of soda in treatment of 

skin diseases, 76, 1439 
Cafe au lait patches, 666 
Calculi, cutaneous, 1129 
Callositas, 586 

in monkevs, 587 
Callositv, 586 
Callus. 586 
Calvities, senile, 1201 
Cancer, chimney-sweep's, 999 
en cuirasse, 992 
" from arsenic, 474 
Cancroid ulcer, 1009 



1444 



INDEX. 



Cancroid, 994 
Canities, 658, 1193 
Cannabis Indica, eruptions from, 482 
Cantharides dermatitis, 462 
" eruptions, 482 

Capillary nevi, 962 
Capsicum eruptions, 482 
Caraate, 1335 
Carbolic acid in the treatment of skin 

eruptions, 80 
Carbuncle, 260 
Carbunculus, 260 

columnae adiposse in, 
262 
Carcinoma cutis, 991 

" epitheliale, 994 

" lenticulare, 992 

" tuberosum, 993 

Carrion's disease, 1067 
Cascadoe, 1323 
Causalgia, 704, 715 
Caustics, formulae for, 1430 

" in the treatment of lupus, 

794, 1420, 1421 
" in the treatment of skin 

diseases, 90 
Celluloma, cystic eruptive epithelial, 

978 
Cerebelliform mole, 959 
Cerebriform mole, 959 
Chalazion, 1129 

Chancre, phagedenic syphilitic, 872 
Charbon, 513 
Cheilitis exfoliativa, 413 
Cheiro-pompholyx, 2S8 
Cheloid, 933 

" Addison's, 628 
" Alibert's, 933 
Chignon fungus, 11 76 
Chigoe, 1384 

Chilblain circulation as a cause of 
skin disease, 63 
" lupus, 62, 822 

Chilblains, in 

Children, acquired syphilis in, 877 
" atrophy of the skin in, 694 

" comedones in, 1135 

" congenital syphilis in, 878 

" diseases of the skin in, 56 

" eczema in, 195, 196 

" erythema exudativum in, 

128 
" gangrene of the skin in, 527 

" keratosis pilaris in, 592 

*' ' lepra in, 906, 910 
" lichen pilaris in, 549 

" " planus in, 435 

" scrofulosus in, 448 

" lupus erythematosus in, 

823 
" pemphigus in, 250 



Children, pityriasis rubra in, 398 
" psoriasis in, 364 

scabies in, 1361 
sclerodermia in, 622 
seborrhea in, 1 in 
Chills in diseases of the skin, 63 
Chimney-sweep's cancer, 999 
Chionyphe Carterii, 1348 
Chinolin eruption, 482 
Chloasma, 665, 1327 

" in Graves' disease, 667 

local causes of, 663 

symptomatic, 665 

" uterinum, 666 

Chloral hydrate, eruptions from, 482 

Chloralamid " " 483 

Chlorate of potassium, eruptions 

from, 484 
Chloroform, eruptions from, 484 
Chloroma, 1386 
Chorionitis, 615 
Chorioptes acarus, 1369 
Chromidrosis, 1093 
Chrysarobin, eruptions from, 461 
Cicatrices, definition of, 43 
Cicatricial alopecia, 1232 
Cimex lectularius, 1386 
Circulation, disturbance of, as a 

cause of skin disease, 62 
Circumscribed sclerodermia, 615, 62S 
Classification, 96 
Clavus, 582 

" disseminated, 582 
Cleavage of the skin, 45 
Climacteric as a cause of skin dis- 
ease, 57 
Climate as a cause of skin disease, 50 
Clinical examination of bacilli and 

fungi, 1406 
Clothing as a cause of skin disease, 

52 
Clou de Biskra, 1069 
Cnidosis, 155 
Coco, 1057 

Cocus wood eruption, 465 
Codeia eruption, 484 
Cod liver oil, eruptions from, 484 
Cold freckles, 660 
Coley's fluid, 1439 

"in mycosis fungoides, 
1056 
" " in sarcoma, 1026 

Collodion in the treatment of skin 

diseases, 91 
Colloid degeneration of the skin, 755 

" milium, 755 
Colored sweating, 1097 
Comedones, 1133 
Comedones, grouped, 1134 
" in children, 1135 
" scar, 1134 



INDEX. 



1445 



Concretions on the hair, 11 71 
Condyloma acuminatum, 578 
Condylomes acuminees, 578 
Congenital achroma, 673 

defect of the cutis, 1131, 

note. 
elephantiasis, 649 
ichthyosis, 566 
leukasmus. 673 
leukodermia, 673 
leukopathia, 673 
monilithrix, 1192 
syphilis, 878 
Congestions, 107 
Congestion, general, of skin, 108 
Congestive mottling of the skin, 107 
Conglomerative pustular folliculitis, 
1288 
" perifolliculitis, 1290 

Conorhinus sanguisugus, 1386 
Constitutional causes of skin disease, 

family, 54 
Constitutional causes of skin disease, 

personal, 54 
Constitutional causes of skin disease, 

race, 54 
Constitutional predisposition to skin 

eruptions, 57 
Contagion as a cause of skin disease, 

53 
Coolie itch, 1391 
Copaiba, eruptions from, 484 
Cor, 582 
Corn, 582 

Corne de la peau, 584 
Cornu cutaneum, 584 

" " epithelioma in, 585 

" humanum, 584 
Counter-irritation in the treatment 

of skin diseases, 83 
Couperose, 1147 
Cowpox, accidental inoculation of, 

518 
Crab louse, 1381 
Crateriform ulcer, 1012 
Craw-craw, 1389 
Croton oil eruptions, 462 
Croutes, 41 

Crusts, definition of, 41 
Cubebs, eruptions from, 485 
Culex pipiens, 1386 
Cutaneous calculi, 1129 

" horn, 584 

Cute, 1335 

Cuterebra, 1387, ?iote> 
Cystadenoma, benign epithelial, 978 
Cystic eruptive epithelial celluloma, 

978 
Cysticercus cellulosae cutis, 1396 
Cysts, atheromatous, 1126 

" dermoid, 1128 



Dan dr iff, 1113 

Darier's disease, 604 

D'Arsonval's high frequency and 

high tension currents, 94 
Darte rongeante, 762 
Deciduous skin, 123 
Degenerative atrophy, 63o 

symptomatic atrophy, 
681, 697 
Delhi boil, 1069 
Demodex folliculorum, 1133, I 369 

pigmentation 

due to, i3~o 

Dentition as a cause of skin disease, 

56 
Depilating folliculitis of the limbs, 

1247 
Dermalgie, 715 

Dermanyssus avium et gallinae, 1369 
Dermatalgia, 715 
Dermatites polymorphes doulou- 

reuses, 326 
Dermatitis, 457 

" artefacta, 467 

calorica, 458 
contusiformis, 137 
exfoliativa, 389 

neonotorum, 
252, 399 
gangrenosa infantum, 

535 

f Variations, 329 " 
" herpeti- j Etiology, 333 

formis \ Pathology, 336 y 
326 j Diagnosis, 337 

[_ Treatment, 338 J 
medicamentosa, 469 

" theory 

of, 506 

papillaris capillitii, 937, 

1243 
psoriasiformis nodularis, 

443 
recurrens, 346 

" aestivalis. 346 

hiemalis, 349 
C Pathogeny, 23S ) 
" repens-] Diagnosis, 238 -235 

( Treatment, 239 ) 
" traumatica, 457 

variegata, 443 
" venenata, 460 

X-ray, 458 
Dermatolysis, 948, 949 
Dermato-myoma, 955 
Dermato-sclerosis, 615 
Dermatobia noxalis, 1387, note. 
Dermatosis of Kaposi, 681 
Dermographism, 159 



1446 



INDEX. 



Dermoid cysts, 1127 

" " multiple, 1127 

Desquamation, quinine causing per- 
sistent, 505 
Diabetes as a cause of skin disease, 
61 
bronzing of the skin in, 667 
Diabetic gangrene, 543 
Diagnosis, general, 68 
Diascopy, 93 
Dietary in the treatment of eruptions, 

73 
Diffuse idiopathic atrophy of the 

skin, 692 
Digestion in diseases of the skin, 59 
Digitalis, eruptions from, 486 
Discoloration of the hair, 1199 

" " skin from matter 

foreign to the 
blood, 671 
Diseases due to pus cocci, 239 
" of the appendages, 1087 
" " hair follicles, 1171 
" " " nails, 1248 

" « «« sebaceous glands, 

mo 
" " " sweat glands, 1087 

Dissection wounds, 507 
Disseminated clavus, 583 

" follicular lupus, 1 164 

Distemper louse, 1380 
Distoma hepaticum embryos in skin, 

1397 
Distribution of eruptions, 45 

" " " descriptive 

terms of, 

47 
" " " vaso-motor 

ce nters 
in, 47 
Diuretics in the treatment of skin 

diseases, 82 
Dracontiasis, 1392 
Dracunculus medinensis, 1392 
Drug eruptions, 469 

" forms of, 504 

Dulcamara eruptions, 486 
Dusting powders in the treatment of 

skin eruptions, 88 
Dysidrosis, 288 

" of the face, 1107 

Dystrophic papillaire et pigmentaire, 

597 
" papillo-pigmentaire, 597 



E 

Ecchymomata, 549 
Ecchymoses, 34, 549 
Echinococcus hydatid, 
Ecthyma, 249 



Ecthyma, bromin causing, 505 
gangrenosum, 535 
" terebrant, 535 

" " due to bacillus 

pyocyaneus, 539 
f Etiology, 199 1 1 ' 

I Diagnosis, 211 
I Pathology, 206 
T?~^rv,o J Treatment: 

Internal, 217 
Local, 221 
According to posi- 
tion, 229 
acute, 193 
capitis, 194 
chronic, 193 
circumscriptum (?) parasiti- 

cum, 234 
drugs causing, 505 
epidemic, see Epidemic Ex- 
foliative Dermatitis, 410 
erythematosum, 191 
exfoliant des levres, 413 
folliculorum, 198 
genitalium, 195 
hypertrophicum seu tubero- 
sum, 1042 
impetiginodes, 189 
impetigo, 189 
in children, 195, 196 
in the aged, 216 
in the course of nerves, 204 
infantile, 195 
intertrigo, 113 
locale, 194 
madidans, 191 
marginatum, 13 13 
mercuriale, 200, 495 
nails in, 195 
nervous, 199 
orbiculare, 191 
palmare, 194, 1122 
papillomatosum, 194 
papillosum, 190 
parasiticum, 234 
pastes in, 224 
primary forms of, 186 
pustulosum, 189 
renal disease in, 205 
rimosum, 195 
rubrum, 189, 191, 211 

scrofulosorum, 192 
sclerosum, 193 
seborrhoicum, 



397 



simplex, 190 
solare, 200 
spargosiforme 
spas in, 228 
squamosum, 188 



195, mo 
squamosum, 
1113 



193 



192 



INDEX. 



1447 



Eczema, sulplmre. 200 
sweat, 19S 
" trade, 201 

verrucosum, 194 
vesiculosum, 187 
Eczemaform seborrhoeide, 11 20 
Eczema-lupus, so-called, 827 
Elastic-skinned man, 950 
Electricity in the treatment of skin 

diseases, 93 
Electrolysis for hirsuties, 1182, 1183, 

1 1 84 
" keloid, 943 
" moles, 961 
" nevi, 965 
*' telangiectases, 969 
in the treatment of skin 
diseases, 93 
Elephant leg, 645 

f Etiology, 650 ] 

Elephantiasis §££*£•# \<»S 

[Treatment, 653 J 
Arabum, 645 
" congenital, 649 

erysipelas as a cause 
of, 652 
" filaria sanguinis homi- 

nis in, 652 
" Grsecorurn, 900 

" Indica, 645 

" lymph-tumor, form of, 

649 
" lymph-scrotum in, 649 

nevoid, 649 
" telangiectodes, 649 

lymph - 
angiectodes with, 649 
various localizations of, 
648 
Elephantoid fever, 646 
Embryogenic growths, 932 
End atrophy of the hair, 1191 
Endothelioma capitis, 1027 

tuberosum multiplex 
colloides, 978 
Endurcissement athrepsique, 640 
Enema rash, 118 
Engelure, in 

Entozoon folliculorum, 1369 
Eosinophilia, 65, 313, note. 
Ephelids, 659, 660 
Ephidrosis, 1087 
Epidemic eczema. 410 

exfoliative dermatitis, 410 
skin disease, 410 
Epidermoly- { "\ 

sis bullo- ! Pathology, 294 I 
sa heredi- ] Diagnosis, 295 \ 93 
taria [_ J 

Epithelial cancer, 994 



Epithelialkrebs, 994 
Epithelioma, 994 

" adenoid, of the sweat 

glands, 978 
adenoides cysticum, 982 
" benign, with colloid de- 

generation, 978 
cystic benign, 978 
*' deep seated, 995, 998 

" in lupus ervthematosus, 

823 
in lupus vulgaris, 768 
lobulated, 1000 
" multiple benign cj-stic, 

982 
papillary, 995 
superficial discoid, 996 
superficial papillary, 
996 
Epitheliome, 994 

Epitheliomes kystiques benins, 978 
Equinia, 510 
Erbgrind, 1265 
Ergot eruptions, 486 
Erntmilbe, 1372 
Erysipelas a cause of elephantiasis, 

652 
Erysipeloid, 508 
Erythema, 108 

ab igne, no 
annulare, 127 
bullosum, 128 
circinatum, 127 
elevatum diutinum, 142 
epidemicum, 154 
exudativum, 125 

" in children, 

128 
" multiforme 

after vacci- 
nation, 523 
fugax, 115 
gangrsenosum, 532 
gyratum, 127 
hsemorrhagicum, 147 
hypersemicum, group i., 

109 
hypereemicum, group ii., 

"115 
induratum, 811 
intertrigo, 113 
iris, 127, 133 
keratodes, 590 
laeve. 114 
marginatum, 127 
f Varieties, 127 "] 
Er^'thema, j Etiology, 128 

multi- { Pathology, 129 y 126 
forme j Diagnosis, 130 

[_ Treatment, 132 J 
Erythema, nodosum, 137 



1448 



INDEX. 



Erythema, nodosum , treatment of, 141 
" papulatum, 127 

" paratrimma, 115 

" pernio, in 

" purpuricum seu hsemor- 

rhagicum, 146 
" purpuricum and inter- 

nal hemorrhages, 146 
" roseola, 115 

" scarlatiniforme, 117 

*' " desquamati- 

vum seu 
recidivans, 
120 
" " due to ene- 

mata, 118 
'* " due to se- 

rum, 118 
" " due to sew- 

er-gas, 118 
" " in go nor- 

rhea, 118 
•' serpens, 508 

'* simplex, 109 

" tuberculatum, 127 

" tuberosum, 127 

41 uremic, 60 

" urticans, 115 

Erythematous eruptions due to 

drugs, 504 
Erytheme, 108 

" centrifuge, 815 

" induredes scrofuleux, 811 

" noueux, 137 

Erythrasma, 1333 
Erythrodermie exfoliante (Besnier), 

389 
Erythrodermie pityriasique en 

plaques (Brocq), 443 
Erythromelalgia, 715 

following arsenic, 

475 

Essential shrinking of the conjunc- 
tiva, 305 

Esthiomene, 762 

Etiology, general, 50 

Examination for fungi, methods of, 
1264, 1406 

Exanthem, psoriasiform and lichen- 
oid, 443 

Exanthem, syphilitic, 846 

Exanthemata, 34 

Excessive sweating, 1087 

Excoriations, definition of, 42 

Exfoliative inflammation of the lips, 

413 
Exudationes, 125 



Family prevalence as a cause of 
skin disease, 55 



Favns 



1265 



Farcy, 510 

Etiology, 1270 
Pathology, 1272 ( 
Diagnosis, 1275 1 I ' 
Treatment, 1277 ) 
fungus, examination of, 1408 

nature of, 1273 
lupinosa, 1267 
of the non-hairy parts, 1267 

nail, 1269 
universal, case of, 1268 
Favus-like lesions of oral mucous 
membrane, due to aspergiilus ni- 
grescens, 1278 
Feigned eruptions, 467, 533 
Feuergiirtel, 265 
Feuermal, 962 

Fibroid, recurrent, of the skin, 1023 
( Etiology, 950 ) 

Fibroma ^ Pathology, 951 ( 

1 Diagnosis, 953 I v ^ 
( Treatment, 953 ) 
" fungoides, 946, 1042 

intellectual defects in, 

95i 
lipomatodes, 737 
" molluscum, 944 

" pendulum, 948 

" simplex, 944 

Fibromyoma, 958 
Fibro-sarcoma, 1023 
Ficosis, 1236 
Filaria medinensis, 1392 

" nocturna, as a cause of skin 

disease, 1390 
" " life history of, 651 

" perstans, 1390 
" sanguinis hominis, life his- 
tory of, 651 
varieties of, 651 
Finsen rays in the treatment of skin 
diseases, 94, 789 
" " modified apparatus of 

Lortet and Genoud, 

94 

Fischschuppenausschlag, 559 

Fish-skin disease, 559 

Fissures, definition of, 42 

Flannel rash, 11 24 

Flea bites, 1385 

Flechte, scheerende, 1206 

Fleckenmal, 959 

Flush patch, 47 

Fluxus sebaceus, 11 10 

Follicular disease of the scalp, 11 28 
" lupus, disseminated, 11 64 

Folliculites disseminees symetriques 
des parties glabres a 
tendance cicatricielle, 
1167 
' tuberculeuses, 1167 



INDEX. 



1449 



Folliculitis, 1 135 

barbae, 1236 
conglomerative pustular, 

1288 
decalvans, 1245, 1246 
depilating, of the limbs, 

1247 
exulcerans, 1167 
necrotica, 1248 
tuberculous, 1248 
Food as a cause of skin disease, 53 
Formulae, 141 7 
Fragilitas crinium, 1187 
Frambesia, 1057 
Fraying of the hair, 1187 
Freckles, 659 

" cold, 660 
Fressende Flechte, 762 
Frostbeule, in 
Fungi as pathogenic agents, 64 

staining of, 1406 
Fungus chalazicus, 1125 

foot of India, 1346 
" methods to find, 1264 
Furuncle, 254 
Furuncles, drugs causing, 505 

'Symptoms, 254 ~) 
Etiology, 256 
Furunculus ■{ Pathology, 257 J- 254 
Diagnosis, 258 
Treatment, 258 J 
orientalis, 1069 



Gaboon ulcer, 1069 

Gadbreeze, 1387 

Gafsa button, 1069 

Gale, 1358 

Galvano-cautery in the treatment of 

skin diseases, 93 
Gangrene, diabetic, 543 

" drugs causing, 505 

44 hysterical, 532 

" neurotic, 532 

44 of the skin, 527 

" ,4 " in adults, 541 

" ' 4 " *' children, 

528 

" spontaneous, 532 

" " of the eye- 

lids, 543 

44 symmetrical, 528 

44 tropical, 546 

Gangrenous, single, patches, 539 
Gastrophilus larva, 1388 
Gayle, 509 
Gefassmal, 962 

General hypertrophy of the seba- 
ceous system, 604 

" idiopathic cutaneous atro- 
phy, 692 



General seborrhea, 567 

Geschwiilste, 37 

Geschwiire, 43 

Glanders, 510, 1408 

Glossy skin, 703 

Glyciphagus domesticus, 1368 

Glycosuria and eczema, 205 

Gnat bites, 1386 

Gneis, 11 10 

Gonorrhea, erythema scarlatinif orme 
in, 118 

Goose skin, 36 

Gram's method of staining, 1407 

Granuloma, 36 

annulare, 1082 
fungoides, 1042 
inguinale tropicum, 1076 
pyogenicum, 240, 1081 
trichoph3 T ticum, 1290 
ulcerating, of the pu- 
44 denda, 1076 

Granulome innomine, 1167 

Grasmilbe, 1372 

Graves' disease, abnormalities of pig- 
mentation in, 67, 667 
14 disease and chloasma, 667 

" leukodermia, 667 

Grayness of the hair, 1193 

Grease (horse-pox), accidental inocu- 
lation of, 519 

Green sweat, 1098 

Groin ulceration, 1076 

Grutum, 11 29 

Guaiacum eruption, 486 

Guarana eruption, 486 

Guinea worm, 1392 

Gune, 1323 

Gurtelausschlag, 265 

Gutta rosacea, 1147 
44 rosea, 1147 



Pi 



Hair, concretions on the, 1171 

Hair follicles, diseases of the, 1171 

Hair eaters, 1178 

41 end, atrophy of, 1191 

44 hypertrophy of the, 1179 

" lotions, formulae for, 1424 

" pigmentation of, 058 

14 swelling and bursting of, 11 88 

Hemangio-endothelioma tuberosum 
multiplex, 978, 982 

Hemosiderin, 655 

Hemosiderosis, 659 

Hematidrosis, 549, 551, 1098 

Hematomata, 549 

Hemoglobinuria in symmetrical gan- 
grene, 529 

Hemorrhagiae, 548 

Hemorrhagic bullae, 549 



45° 



INDEX. 



Hemorrhea petechialis, 548 
Hansen's bacillus (bacillus leprae), 

1408 
Harlequin fetus, 566 
Harvest bug, 1372 
Hautabschiirfungen, 42 
Hautfinne, 1136 
Hauthorn, 584 
Hautrothe. 108 
Hautschrunden, 42 
Hautsclerem, 6rs 
Hemiatrophia facialis, 637 
Hemiatrophy of the face, 637 
Heredity as a cause of skin disease, 

54 
Hernia carnosa, 645 
Herpes, 264 

" circinatus, 1309 

" " bullosus, 326 

" desquamans, 1323 

" endemicus, 283 
facialis, 281 

" " shivering before, 282 

" febrilis, 281 

•' gestationis, 326, 332 

" iris, 133, 135 

" "a variety of erythema, 

133, 135 
" " bullous form, of, 136 

" labialis, 281 
" " microbe in, 282 

" local varieties, 265 
" phlyctenodes, 268 
" praeputialis, 265, 284 
" progenitalis, 265, 284 
" pyaemicus, 353 
" recurrent, 283 
" signification of word, 1279, 

note. 
" tonsurans, 1279 
" " maculosus, 406 

" " maculosus et 

squamosus, 

1315 
f Distribution, 267 "| 
I Etiology, 274 I 

" zoster <( Pathology, 276 ^265 
I Diagnosis, 279 
[Treatment, 280 J 

" " aberrant vesicles in, 

" " an acute specific dis- 
ease, 274 
" '* arsenic as a cause of, 

275, 473 

" " atypicus, 287 

*' " complications in, 272 

" " double, 271 

" " from arsenic, 275 

Ci " in children, 274 

" " local forms of, 270 



Herpes zoster recurrent, 271 
Herpes circine, 1309 

esthiomene, 762 
" tonsurant, 1279 
Herpetic fever, 282 
Herpetides, 264 
Herpetism, 264 
Herpetisme, 264 
Hexo-nitro-phenyl-amine eruption, 

465 
Hidebound disease, 615 
Hidradenitis destruens suppurativa, 

1167 
Hidrocystoma, 1107 
High-frequency currents in treat- 
ment of skin disease, 94, 792 
High-tension currents in treatment 

of skin diseases, 94 
Hilliard's lupus, 801 
Hirsuties, 11 79 

electrolysis in, n 82 
Rontgen rays in, 11 85 
" treatment of, 1181 

Honeycomb ringworm, 1265 
Horns, 584 

epithelioma in, 585 
Horse-pox, accidental inoculation of, 

518 
Hot air currents in lupus vulgaris, 

793 
Hiihnerauge, 582 
Hydradenitis destruens suppurativa, 

1167 
Hydradenoma, eruptive, 978 
Hydradenomes eruptifs, 978 
Hydroa, 325 

aestivalis, 341. (See H. vac- 
ciniformis, infra.) 
bulleux, 325, 333 
" febrilis, 281 

" hepetiforme, 325 

" herpetiformis, 326 

iodid, 489 
puerorum, 341 
" pruriginosa, 333 

vacciniforme, 325 

f Etiology, 343 ^ 
„ vaccini- J Pathology, 344 I 
formis ] Diagnosis, 344 j ^^ 
[Treatment, 345 J 
" varieties of, 375 
" vesiculeux, 135, 325 
Hydrosadenitis, phlegmonosa, 255 
Hygienic causes of skin disease, 

general, 50 
Hygienic causes of skin disease, per- 
sonal, 52 
Hyperaemiae, 107 
Hyperesthesia, 714 
Hyperidrose huileuse, 1110 
Hyperidrosis, 1087 



INDEX. 



T45I 



Hyperidrosis, fatal, 728 
Hyperkeratose figuree centrifuge 

atrophiante, 593 
Hyperkeratoses, 573 
Hyperkeratosis eccentrica, 593 

" universalis congen- 

ita, 568 
Hypertrichiasis, 1179 
Hypertrichosis, 11 79 
Hypertrophiae, 559 
Hypertrophic scar, 936 
Hypertrophy, general, of the sebace- 
ous system, 604 
" of the hair, 1179 

Hyphogenic sycosis, 1315 
Hyphomycetic parasites, 1284 

disease, 1355 
Hyperderma bovis, 1388, note. 
Hysterical gangrene, 532 

I 

Ichthyol in the treatment of skin 

eruptions, 81 
Ichthyose nacree, 560 

( Etiology, 569 ) 

Ichthyosis fe^^f 559 
( Treatment, 571 ) 
" acquired, 562 

" congenita, 566 

" cornea, 615, note. 

" follicularis, 610 

hystrix, 563 
" linearis, 563 

" linguae, 565 

" nigricans, 561 

" nitida, 560 

" palmaris et plantaris, 

587 
palmae (see Tylosis), 586 
" sauroderma, 560 

" scutellata, 560 

" sebacea, 567, 11 10 

" " cornea, 604, 610 

" seborrhea, general, and, 

567 
" serpentina, 560 

" simplex, 560 

" vera, 559 

Idiopathic multiple hemorrhagic sar- 
coma, 1028 
Idradenomes eruptifs, 978 
Idrosadenite suppurative disseminee, 

1167 
Idrosis, 1087 
Ignis sacer, 265 
Impetiginous syphilids, 867 

Impetigo ( gH^F' 245 ' ) 
contao-i 1 Pathology, 246 ( 
con tagi- < DiagnosiSt 24S 242 

( Treatment, 248 ) 



Impetigo contagiosa bullosa, 244 
" " gyrata, 244 

" herpetiformis, 351 

" of Bockhart, 244 

of Duhring, 241, note. 
" old varieties of, 189, note, 

241 
" syphilitic, 867 

varioliformis, 11 59, note, 
Induratio telae cellulosse, 640 
Infective angioma, 970 
Infiltration, 36 
Inflammations, 125 
Inflammatory fungoid neoplasm, 1042 
Ingrowing toe-nail, 1251 
Injection of arsenic for sarcoma, 1032 
Injections, formulas for intravenous, 
1438 
" " " subcutaneous 

and in tra- 
in u s c ular, 
1437 
Instruments used in skin diseases, 92 
Internal diseases as causes of skin 

disease, 59 
Intertrigo, 113 
Intestinal disinfectants in treatment 

of skin-diseases, 83 
Iodid acne, 486 

" hydroa, 479, 489 
Iodids, eruptions from, 486 

" in the treatment of skin erup- 
tions, 81 
Iodin, eruptions from, 486 

" in the treatment of skin erup- 
tions, 82 
Iodoform dermatitis, 462 

" eruptions from, 492 

Irritants as a cause of skin eruptions, 

53 
Ischemia, peripheral, 62 
Itch, 1358 

" sarcoptic, from horse, 1368 

11 baker's, 201 

" bricklayer's, 201 

" grocer's, 201 
Itching {see Pruritus), 717 
Ixodes, 13 71 



Jacob's ulcer, 1009 

Jaundice, 671 

Jews and diseases of the skin, 

Jigger, 1384 

Juckblattern, 178 



54 



Kandahar sore, 1069 

Kauti cure for leprosy, 922, note. 



J45 2 



INDEX. 



Keloid 



933 



Etiology, 938 
Pathology, 939 
Diagnosis, 941 
{ Treatment, 942 ) 
" acne 937, 1243 

" en plaque, 938 

" in syringo-myelia, 938 

involution of, 936 
Keloid of Addison, 628 
" " Alibert, 933 
" " " in circumscribed 
s c 1 e r o der- 
mia, 632 
" scars, 936 
Keratodermia erythematosa symme- 
trica, 590 
Keratolysis, 123 

" exfoliativa congenita, 

572 
Keratoma, 586, 588 

hyperidrosis as a cause 
of, 588 
" palmse et plantse heredi- 

tarium, 589 
" senile, 577 

" subungual, 574 

Keratoses, 573 

Keratosis and sweating, 1089 
" follicularis, 604, 610 
" " contagiosa, 574, 610 

" from arsenic, 475 

nigri- ( Etiology, 601 \ 
cans ) Diagnosis, 602 ( 
(papil- j Pathology, 602 f 5 ^7 
laris) ( Treatment, 603 ) 
" nigricans (papillomatosa), 574 
" palmse et plantse, 587 
" " " " and sweat- 
ing, 1089 
" pigmentosa, 577 
" pilaris, 560, 591 
" supra-follicularis, 591 

" 7 Q e £ e " \ Etiology, 607 

ffouicu ' Patbolo 'gy, 6 °7 

aris) 1 Diagnosis, 608 
laris;, Treatment, 609 
574 I v 

Kerion, 1289 

" of the beard, 1289, 1316 
" of the glabrous skin, 1290 
Kidney affections as a cause of skin 

disease, 59 
Kleienflechte, 1327 
Knotchen, 35 
Knoten, 36 
Koch's bacillus, 1410 
Koilonychia, 1207 
Kratze, 1358 
Kraurosis, 696 
Krebs, der flache, 1009 
Krusten, 41 



604 



Kupferfinne, 1147 
Kupferrose, 1147 
Kupfriges Gesicht, 1147 



Lactation as a cause of skin disease, 

57 
Lactophenin eruptions, 494 

Lafa, 1323 

Land scurvy, 550 

Larva migrans of gastrophilus, 1388 

Lassar's paste, 91 

Le Pita, 1323 

Leichdorn, 582 

L'endurcissement athrepsique, 640 

Lentigines, 657 

Lentigo melanosis, 1000 

Lentigo. 659 

senilis, 662 
Leontiasis, 900 
Lepothrix, 1171 

Lepra, as a disused synonym for pso- 
riasis, 354, 357 

( Etiology, 912 \ 

( Treatment, 921 ) 

" alphos, 354 

" anesthesia in, 908 

" communicated by inocula- 
tion, 914 

" contagion in, 913 

" eye-changes in, 904 

" heredity in, 913 

" maculo-anesthetic, 901, 967 

•' mercurial injections in, 925 

" mixed, 901, 907 

" mixed tuberculated, 901 

" nodular, 901 

" non-tuberculated, 901 

" paralysis, gog 

" perforating ulcer in, 909 

" propagation of, 913 

" prophylaxis of, 926 

14 pyrexia in, 901 

" syphilitica, 852 

" tuberculated, 901 

" vaccination and, 914 
Lepre, 900 
Leprosy, 900 

" bacillus, 1408 
" white, 678 
Leprous spot, 902, 905 
Leptus Americanus, 1373 

" autumnalis, 1372 

" irritans, 1373 
Lesions, primary, 33 

" secondary, 40 

" special, 44 

Leukasmus, acquired, 675 



INDEX. 



H53 



Leukasmus, congenital, 673 
Leukemia cutis, 1036 
Leukodermia, 673 

" after jaundice, 678 

and alopecia areata, 

677 
" congenital, 673 

" syphilitic, 874 

Leukonychia, 1256 
Leukopathia, 675 

congenital, 673 
" unguium, 1256 

Leukoplakia syphilitica, treatment 

of, 898 
Lichen, 414 

( Etiology, 422 ] 
" acumi- J Anatomy, 422 ( , 
natus j Diagnosis, 423 f 4 
[ Treatment, 424 ) 
" agrius, 415 
" annularis,. 456, 1082 
" annulatus serpiginosus, 1123 
" circinatus, 41b, 1123 
" circumscriptus, 1121, 1123 
" gyratus, 11 23 
" hypertrophique, 1042 
" lividus, 416, 448, 549 
" menti, 1236 
" obtusus, 428 
" pilaris, 415, 452, 592 

" special variety of, 454 
( Etiology, 435 ) 

" planus < Pathology, 437 f 
planus j Diagnosis> 440 f 425 

' Treatment, 440 J 

" " acute, 427 

*' " annularis, 432 

" " atrophicus, 431 

" " bullae in, 434 

" " erythematosus, 429 

" " erythematous form of, 

429 

" " hypertrophicus, 430 

" " in children, 435 

" " linear, 433 

" " morphceicus, 431 

" u of mucous membranes, 

43i 
" sclerosus, 431 

" " variations in, 428 

" " verrucosus, 430 

" pseudo, varieties of, 415 

" psoriasis, 425 

" ruber, 416 

" acuminatus. See Li- 
chen acuminatus, 
416 

" " moniliformis, 429 

" " planus, 425 

" scrofulosorum, 446 

" scrofulosus, 446 



Lichen scrofulosis, in children, 448 
" simplex, 415 
" spinulosus (Devergie), 452 
" strophulosus, 416 
" syphiliticus, 416 
" telangiectasique, 612 
" trophicus, 416, 1101 
" true and false, 35, 415 
" urticatus, 158, 415 
" variegatus, 443 
" varieties of, 415 
Lichenification, 416 
Lichenoid, 35 
Lichenoid and psoriasiform exan- 

them, 443 
Light treatment, 94, 789 
Linese albicantes, 696 
Liniments, formulae for, 1427 

in the treatment of skin 
eruptions, 87 
Linimentum exsiccans (Pick's), 92 
Linsenmal, 959 
Liodermia essentialis, 681 
Localization in pathology, 67 
Lortet-Genoud Light apparatus, 94 
Lotions, formulae for, 1421 

" varieties of, in the treat- 
ment of skin eruptions, 87 
Louse, 1373 
Lousiness, 1374 
Lupus acutus, 766 

" applications for, 1428 

" disseminated follicular, 1164 

disseminatus vulgaris, 766 
" erythematodes, 815 
'* erythemateux dissemine, 1167 
" erythematosus — 

f Etiology, 823 1 
J Pathology, 824 L 8l , 
] Diagnosis, 826 ( ° 5 
[Treatment, 828 J 
" acute, 818 
" " albuminuria in, 818 
" " bullae in, 818 
" " circumscriptus, 815 
" " disseminatus, 817 
" " epithelioma in, 823 
" " erysipelas-like swellings 

of face, persistent, 818 
" " folliclis in, 823, 1169 
" " in children, 823 
" " involution after erysipe- 
las, 817 
" " nodular, 820 

"of the hands and feet, 820 
" " telangiectic, 819 
" exedens, 762 
" h} T pertrophicus, 766 
" lymphaticus, 974 
" marginatus, 801, 833 
" papillomatosus. 769 



1454 



INDEX. 



Lupus pernio, 822 

" sclereux, 797 

" sebaceus, 815 

" serpiginosus, 766 

" superficialis, 815 

" syphilitic, so-called, 869 

" telangiectodes disseminatus, 

833 
" verrucosus, 797 
" " multiple, 797 

" vulgaire, 762 

f Etiology, 772 ] 
" vul- J Pathology, 776 ! 6 
garis \ Diagnosis, 779 f ' 
I Treatment, 783 J 
" elephantiasis in, 769 
" " epithelioma in, 769 

" " erysipelas in, 768 

" " erythematodes. 768 

" fibromatosus, 767 
" " herpetic distribution 

of. 766 
" " inoculation of, 773 

" " multiple, 765 

" of mucous membranes, 

77i 
" "of the vulva, 764 

" " phthisis in, 773 

" " phototherapy in, 789 

" " Rontgen rays in, 789 

" '* thiosinamin in, 785 

" " thyroid extract in, 783 

" * 4 tuberculin treatment 

in, 784 

Lupus-psoriasis, so-called, 827 

Lymphadenie cutanee, 1042 

Lymphangiectasis, 612, 973 

Lymphangiectodes, 974 

Lymphangioma, 973 

Lymphangioma capillare varicosum, 

974 
" cavernosum, 974 

" circumscriptum, 974 

" cystic, 974 

" tuberosum multiplex, 

978 
Lymphangiomyoma, 959 
Lymphodermia perniciosa, 1042 
Lymph scrotum, 649 
" tumors, 649 



M 



Maculae atrophica?, 699 
" cerulean, 1382 
'■' definition of, 33 

Macules, 33 

Madagascar ulcer, 1075 

Madura foot, 1346, 1409 

Mai de la Baie de St. Paul, 835 
" "la rosa, 149 



Mai de los pintos, 1335 
" del pinto, 1335 
" de Meleda, 587, 589 
" roxo, 149 
Malabar ulcers, 544 
Malignant papillary dermatitis, 1004 

pustule, 513, 1407 
Massage in the treatment of skin 

diseases, 95 
Mechanical means in the treatment 

of skin diseases, 92 
Medicinal eruptions, 469 
Medicines as a cause of skin erup- 
tions, 53 
Megalonychosis, 1258 
Melanin, 655 
Melanodermia, 663 
Melanopathia syphilitica, no, note. 
Melanosis, actinic, 659 
reflex, 659 
toxic, 659 

lenticularis progressiva, 
6S1 
Melanotic growths, 658 
sarcoma, 1019 
whitlow, 102 1 
Menopon pallidum Nitzschii, 1369 
Menstruation as a cause of skin erup- 
tion, 57 
Mentagra parasitica, 1315 
Mercurial intramuscular injections, 

formulae for, 1437 
Mercury, dermatitis, 462, 494 

" eruptions from, 462, 494 
Methods of staining bacilli and fungi, 

1406 
Microsporon Audouini, 1281 

" geographical 
distribution of, 
1281 
" " persistent scali- 

ness due to, 
1284 
•' variations of 
ringworm due 
to, 1284 
" furfur, 1329 

minutissimum, 1334 
Miliaria, 1101 

" alba, noi 
" crystallina, 1101 
" palmee etplanUe, 1102 
" papulosa, 1 102 
" rubra, noi 
" vesiculosa, noi 
Miliary fever, 1103 

" tuberculosis of the skin, 802 
" tuberculosis of the skin, 
chronic, 804 
Milium, 1129 

" congenitale (en plaques), 1131 



INDEX. 



J 455 



Milium grouped, 1131 

in pemphigus, 306, 1130 
Milzbrand, 513 

Mineral waters in the treatment of 
skin eruptions, 82 
varieties of, 1410 
Mixtures, formulae for, 1435 
Moist wart, 578 
Mole, pigmentary, 959 
Moles, distribution of, 960, 961 
varieties of, 959 
" white, 959 
Mollin soap in treatment of skin dis- 
eases, 85 
Molluscum cholesterique, 737 

( Etiology. 731 ) 
,, contagi- ) Pathology, 733 f 
osum, j Diagnosis, 735 /" ' v 
( Treatment, 736 ) 
Molluscum contagiosum, peculiar 
forms of, 730, 731 
contagiosum , Turkish 
baths as a cause of, 
732, note. 
fibrosum, 944 
" giganteum, 730 

pendulum, 944 
" sebaceum, 729 

" sessile, 729 

" simplex, 944 

" verrucosum, 729 

Moniliform hair, 1191 
Monilithrix, 11 91 
Morbi appendicium, 1087 
Morbus elephas, 645 
Morbus maculosus Werlhofhi, 550 
Morphia, eruptions from, 496 
Morphea, 628 

atrophica, 630 
" lardacea, 631 

maculosa, 631 
" nigra, 631 

" not local leprosy, 637 

" tuberosa, 631 

Morpion, 1381 
Mortimer's malady, 1034 
Morvan's disease, 727 

" leprosy simula- 

ting, 709 
Morve, 510 
Mosquito bites, 1386 
Mottling, congestive, of the skin, 107 
Mouilla soap in the treatment of skin 

diseases, 85 
Mower's mite, 1372 

Mucous tubercles in congenital syphi- 
lis, 882 
Multiple atheromatous cysts, 1126 

benign t u m o r-like new 
growths, 702 
" dermoid cysts, 1127 



Mycosis 
fun- 
goides 



1042 



1051 



Multiple fungoid papillomatous tu- 
mors, 1042 
gangrene of the skin in 

adults, 542 
gangrene of the skin in in- 
fants, 527, 535 
sarcoma of the skin, 1023, 
1024 
" See also Myco- 

sis fungoides, 
1042 
sarcoma, congenital, 1025 
Muscle tumor, 955 
Mustard, eruptions from, 462 
Mycetoma, 1346, 1409 

varieties of, 1346, 1348 
Etiology, 1051 ] 
Pathology, 1052 
Diagnosis, 1054 
Treatment, 1055 } 
like leprosy, 1054 
" yaws, 1042 
" tumeurs d'embleein, 

" types of, 1043, 1044 

Mycosis microsporina, 1327 
Myiasis, 1387 
Myoma, 955 



N 



Nackenkeloid, 1243 
Nevi, 932 

" cystic epithelial, 978 
" symetriques de la face, 986 
" vasculaires et papillaires, 986 
Nevoid elephantiasis, 649 
Nevus, acneiform, 11 34 
" araneus, 967 
" capillary, 34, 962 
44 flammeus, 962 
" folliculosus, 1 13 1 
" lipomatodes, 959 
" lupus. See Angioma serpig- 

inosum, 970 
" neuroticus unius lateris, 564 
" papillaris, 564 
" papillomatosus, 969 
" pigmentaire, 959 
" pigmentary, 657 
" pigmentosus, 959 
" pilosus, 959, 1 180 
" sanguineus, 962, 968 

spilus, 959 
" treatment, 964 
" vascularis, 962 
" vasculosus, 962 
" verrucosus, 564, 969 
Nail, atrophy of, 1254 
Nails, diseases of, 1248 

" " etiology of, 1258 
" " " heredity in, 1258 



M56 



INDEX. 



Nails, diseases of, treatment of, 1261 

" favus of the, 1269 

" furrows of, 1261 

" in alopecia areata, 1210 

44 influence of arsenic on, 474 

" reedy, 1260 

" ridged, 1255 

44 separation of the, 1255 

" shedding of, 1252 

" spoon, 1257 

" supernumerary, 1258 

4: syphilitic affections of, 877 

" tylosis of matrix of, 1257 
white, 1256 

spots on, 1256 
Narben, 43 

Nassende Flechte, 186 
Natal sore, 1070 
Natural mineral waters and spas, 

1410 
Negroes and diseases of the skin, 54 
Neoplasms, 728 
Nerve nevus, 564 

" tumor, 954 
Nervenschmerz der Haut, 715 
Nervous lesions as a cause of skin 

disease, 66 
Nesselausschlag, 155 
Nesselsucht, 155 
Nettle rash, 155 
Neuralgia of the skin, 715 
Neuro-fibroma, 944 
Neuroma, 954 

Neuropathic papilloma, 564 
Neuroses cutaneae, 714 
Neurotic excoriations, 469 
Nevrome, 954 
New growths, 728 
Nigua, 1384 
Nodulae, 36 

Nodular necrotic phlebitis, 814 
Nodules, 36 
Noli me tangere, iocg 
Noma, 527 

Non-pigmented sarcoma cutis, 1022 
Norwegian itch, 1361 



O 



Occupation as a cause of skin dis- 
ease, 52 
CEdema, acute circumscribed, 157 
neonatorum, 643 
of the new-born, 643 
persistent of face, 650 

" solid of face, 650 

wandering, 157 
CEstrus, 1387 
Oils, formulae for, 1427 
" in the treatment of skin dis- 
ease, 87 



Ointments, formulae for, 1425 

" in the treatment of skin 

disease, 85 
" varieties of, in the treat- 

ment of skin disease, 

85 
Oleates in the treatment of skin dis- 
ease, 92 
Onychauxis, 1252, 1258 
Onychia, 1250 

Onychogryphosis, 574, 1251, 1258 
Onychomycosis, 1252, 1321 

" fungi in, 1288 

treatment of, 1308 
Onychorrhexis, 1253 
Ophiasis, 1265 
Orange patches, 665 
Oriental boil, 1069 
Orientbeule, 1069 
Oroya fever, 1067 
Orthoform eruptions, 462 
Osmidrosis, 1092 
Osteosis of epidermis of sole, 1129 



Pachydermia, 645 

Paget's disease affecting the penis, 
1006 
44 " of the nipple, 1004 

" " " pubes, 1006 

44 " affecting the scrotum, 

1005 
11 vulva, 1006 

Paludides, 51 
Panaris analgesique, 707 
Pannus carateus, 1335 
Papilloma area elevatum, 1080 
neuropathicum, 564 
" neuroticum, 564 

" of the skin, 1079 

Papulae, definition of, 35 
Papular seborrheid, 1123 
Papules, definition of, 35 
" in purpura, 549 
Papulo-ulcerative, follicular, hy- 

phomycetic disease, 1355 
Paqiielin's cautery in the treatment 

of skin disease, 93 
Parakeratosis variegata, 443 
Parangi, 1057 
Paraphenylene diamin, hydrochlo- 

rate of, eruption, 464 
Paraplasts, 90 
Parasitare Bartfinne, 131 5 
Parasites, hyphomycetic, 1284 

animal, 1357 
Parasitic diseases, vegetable, 1284 
<< a << varie- 

ties of, 
1284 



INDEX. 



1457 



Parasitic sycosis, 1315 
Parasiticides, formulae for, 1431 

" in the treatment of 

skin diseases, 88 
Paronychia, 1251 

gangrenosa, 528 
Passive congestion, 107, 108 
Pastes, formulas for, 1428 

hard in the treatment of skin 
diseases, 90 
" in the treatment of eczema, 
224 
soft, in the treatment of skin 
diseases, 90 
Patches, cafe-au-lait, 34, 665 
mucous, 870 
" orange, 34, 665 
" pigmentation, 35 
" white, 35 
Pathology, general, 64 
Pediculosis, 664, 1373 

" pyrexia in, 1379 

Pediculus capitis, 1374 
" corporis, 1377 

" hemorrhagic 

specks in, 1378 
" " pigmentation, due 

to, 664, 1379 
" pubis, 1381 

" green coloring-mat- 
ter of , 1383 
Pediculus pubis on the eyelids, 1382 
" " on the head, 1382 

" tabescentium, 1380 
vestimenti, 1377 
Pelade, 1209 

Peladoid ringworm, 1284 
Peliosis rheumatica, 144, 551 

" " and cardiac com- 

plications, 146 
Pellagra, 149 

insanity in, 151 

f Etiology, 316 1 

Pemphigus ]g*$g; HI \«X 

[_ Treatment, 322 J 

" acutus, 299, 300 

" " in butchers, 299 

" " in children, 300 

" benignus, 303 

chloroticus, 298 

*' chronicus, 300 

" circinatus, 304, 326 

" congenital traumatic, 293 

" contagiosus, 253 

" " tropicus, 253 

" diphtheriticus, 302 

" diutinus, 302 

" epidemic, 252 

" foliaceus, 306 

" " tylosis in, 305 

92 



Pemphigus gangraenosus, 302, 535 
haemorrhagicus, 302 
hystericus, 297, 303 
in children, 250 
leprosus, 295 
localis, 302 
malignus, 303 
milium in, 306 

( Etiology, 251 ) 
neona-< Diagnosis, 252 >• 250 
torum ( Treatment, 254 ) 
neuroticus, 296 
of conjunctiva, 304 
of mucous membranes, 305 
pruriginosus, 303, 306 
solitarius, 302 
syphiliticus, 295 
tylosis in, 305 
vegetans, 311 
virginum, 298 
Pendjeh sore, 1069 
Pendulous tumors, 948 
Perforating ulcer affecting the hand, 
705 
" of the foot, 705 
Perifolliculitis, conglomerative pus- 
tular, 1288, 1290 
Pernio, in 

Persistent edema of face, 650 
Personal constitutional conditions in 

diseases of the skin, 55 
Peruvian wart, 1067 
Petechias, 34, 549 
Phagedasna syphilitica, 872 

tropica, 544 
Phagedenic chancre, 872 
Phaneroscopy, 93 
Phenacetin eruption, 497 
Phenyl-hydrazin-hydrochlorid erup- 
tion, 463 
Phenyl-hydroxylamin eruption, 497 
Phlegmasia Malabarica, 645 
Phosphorescent sweat, 1099 
Phosphoric acid, eruption from, 497 
Phosphorus in the treatment of skin 

eruptions, 79 
Phototherapy, 94, 789 
Phthiriasis, 1373, 1381 
Phthirius pubis, 1381 
Pian, 1057 

fungoide, 1042 
" ruboide, 1245 
Picric acid, yellow staining from in- 
ternal administration of, 677 
Piebald skin, 675 
Piedra, 1175 

nostras, 11 76 
Pigmentary mole, 959 

" " nevi, 959 

Pigmentation, anomalies of, 35, 655 
" drugs causing, 505 



458 



INDEX. 



405 



Pigmentation from arsenic, 474, 672 

" in diabetes, 667 

" in Graves' disease, 667 

pathology of, 655 

Pigmented pityriasis rubra, 362 

psoriasis, 362 

Pigmentmal, 959 

Pills, formulas for, 1433 

Pimples, 35 

Pinta, 1335 

Pita, le, 1323 

Pityriasis, 11 10 

" des levres, 413* 

" lichenoides chronica, 443 

" maculata et circinata, 

405 

" nigra, 664. 1329 

" nigricans, 1093 

" pilaris, 591 

f Etiology, 408 

" rosea J Pathology, 408 
rosea <j Diagnosis> 4Qg 

[Treatment, 410 J 
" " primitive patch in, 406 

f Etiologv, 399 ") 
" rubra i ^ atholo V' 400 I g 
j Diagnosis, 403 j J y 
[Treatment, 404 J 
Pityriasis rubra aigu (Devergie), 389 
" " dermatitis exfolia- 

tiva neonatorum 
and, 399 
" " Brocq's classifica- 

tion of, 390, note. 
" " (Hebra), tuberculo- 

sis in, 397 
" " Hebra type, 396 

" " in children, 398 

" " pilaris: see Lichen 

acuminatus, 416 
" " after pityriasis 

rubra, 393 
'• " rheumatic symp- 

toms in, 395 
" " with bullae, 392 

" simplex, 193, 1113 
" versicolor, 1327 
Plants, eruptions from irritant, 

465 
Plaque, the primary, 65, 356 
Plaques ortiees, 39 
Plaster muslins in the treatment of 

skin diseases, 91 
Plasters, formulas for, 1429 
Plica, 1 1 78 

" neuropathica, 1178 

" polonica, 1178 
Podelcoma, 1346 
Poliothrix, 1193 
Polytrichia, 11 79 
Pomphi, definition of, 39 



Pompholyx 



Etiology, 290 \ 
Pathology, 290 ( g 
Diagnosis, 291 t 
[ Treatment, 292 ) 
Porcupine men, 563 
Porokeratosis, 574, 593 
Porrigo contagiosa, 242 
11 decalvans, 1209 
" favosa, 1265 
" furfurans, 1279 
"' lupinosa, 1265 
Port-wine mark, 962 
Post-mortem pustule, 508 

sweating, 1090 
warts, 797, 749 
Potassium chlorate, eruptions from, 

484 
Poultices in the treatment of skin 

diseases, 85 
Powders, dusting, formulae for, 1430 
" in the treatment 
of skin diseases, 
88 
formulae for, 1434 
Pregnancy as a cause of skin disease, 

57 

Prickly heat, 1101 
Primary lesions, 33 
Primary plaque, the, 65, 356 
Primula obconica dermatitis, 467 
Proptosis from urticaria, 156 
Protozoic dermatitis, 1354 
f Varieties, 179 ^ 
i Etiology, 180 
Prurigo { Pathology, 181,^ 178 
I Diagnosis, 182 j 
[ Treatment, 183 J 
ferox, 178 
mitis, 178 

relation of, to urticaria, 
180 
Pruritus, 717 

ani, 718, 720 
" aestivalis, 719 

" hiemalis, 719 

local. 720 

palmae et plantae, 719 
" scroti, 721 

" senilis, 719 

treatment of, 722 
universalis, 718 
" vulvae, 718 

Pseudo-colloid of lips, 758 
Pseudo-leukemia cutis, 1037 
Pseudo-pelade, 1232 
Pseudo-pellagra due to alcoholism, 

Pseudo-xanthoma elasticum, 747 
Psora, 354 

Psoriasiform and lichenoid exan- 
them, 443 



INDEX. 



: 459 



Psoriasiform seborrheic!, 1122 
f Etiology, 364 "| 
I Pathogeny, 368 j 

Psoriasis J Pathology, 368 I 
Psoriasis <j DiagllosiS) 373 f ->54 

J Treatment, 377 j 
L " local, 3S3 J 

" achromia after, 362 

" acuta, 358 

after borax, 366 

" circinata, 357 

" complications, 361 

" contagion, 367 

" diffusa, 356 

discoidea. 356 
drugs causing (?), 505 

" eczemateux, 358 

" empyodes, 357 

epithelioma in, 363 

" follicular, 361 

" guttata, 356 

gyrata, 357 

" heredity and, 365 

" in children, 364 

" injuries, 366 

" inoculation of, 367 

" inveterata, 357 

" keloid after, 363 

'* labialis, 413 

" mucous membranes in, 360 

" nigra, 362 

" nummularis, 356 

" of the nails, 360 

palmae et plantae, 358 
palmaris et plantaris, 853 

" papillary hypertrophy in, 

363 

" pigmentation alter, 362 

" pilaris, 455 

primary plaque, the, in, 

350 
" punctata, 356 

" rupioides, 357 

scalp, 358 
" scarring after, 363 

sequelse, 361 

striata, 359 
" sweat-duct, 361 

" syphilitic. 850 

universalis, 356 
" vaccination and, 367 

warty hypertrophy in, 363 
Psorosperms as pathogenic agents, 

64 
Psorospermose folliculaire vegetante, 

604 
Pterygium, 1249 
Puberty as a cause of skin disease, 

5 6 
Pulex irritans, 1385 

" penetrans, 1384 



( Etiology, 551 ) 
Purpura \ Pathology, 5*3 [ 
^ ) Diagnosis, 556 1 " 4 

( Treatment, 557 ) 
bacteria and bacilli in, 554 
" bullosa, 302 

febrilis, 551 
haemorrhagica, 550 
" morbid changes in the 

sympathetic ganglia in, 
555 
neonatorum, 552 
papulosa, 549 
rheumatica, 144, 551, 556 
senilis, 550 
simplex, 549 
" thrombotica, 147 

turpentine in, 557 
urticans, 157 
Purpuric eruptions, drugs causing, 

505 
Puru, 1070 
Pusteln, 39 
Pustula maligna, 513 
Pustulse, definition of, 39 
Pustular eruptions, drugs causing, 

505 
Pustular ringworm, recent, 1291 
Pustules, definition of, 39 
Pyodermite vegetante, 314 



Q 



Quaddeln, 39 
Qualitative atrophy, 6S0 
Quantitative " " 680 
Quincke's disease, 157 
Quinine, eruptions from, 497 

in the treatmeut of skin 
eruptions, 78 
Quinone eruptions, 464 
Quirica, 1335 



R 



Race and diseases of the skin, 54 
Radezyge, 835 

Radium in treatment of lupus vul- 
garis, 792 
Ray fungus, 1339, !343- J 4o6 
Raynaud's disease, 528 

and sclerodermia, 
622 
Recklinghausen's disease, 944 
Recurrent fibroid of the skin, 1023 
Recurring summer eruption, 346 
Red gum, 1102 

" sweat, 1098 
Resins, eruptions from, 500 
Resorcin in the treatment of skin 
eruptions, Si 



1460 



INDEX. 



Respiratory diseases as a cause of 

skin disease, 62 
Rhagades, definition of, 42 
Rheumatism of the skin, 715 
Rhinophyma, 1148, 1150 
Rhinoscleroma. 927 
Rhubarb, eruption from, 500 
Rhus dermatitis, 465 
Rhynchoprion penetrans, 1384 
Ringed hairs, 1196 
Ringworm, 1279 

" beard, 1315 

" black dot, 1286 

" examination of fungi of, 

1409 
11 of the body, 1309 

" '* eyelashes, 1320 

" " scalp, 1279 

" yaws, 1060 

[ Etiology, 1013 ) 
Rodent J Pathology, 1014 ^ 
ulcer J Diagnosis, 1016 1 9 
( Treatment, 1017 ) 
Rodent ulcer in early life, 1014 
Rontgen rays and telangiectases, 968 
" in treatment of skin 

diseases, 93, 789, 943, 
961, 1185 
Rosacea, 969, 1147 

" acuminata, 1149 
Rose rash, 108 
Roseola, 34, 115 

" idiopathic, 116 
" needless varieties of, 115 
" symptomatic, 115 
" syphilitic, acquired, 846 
" " congenital, 881 

11 vaccina, 521 
Rotz, 510 
Rouget, 1372 
Rupia, 864 

escharotica, 535 



Salicin eruption, 501 

and salicylates in treatment 
of skin diseases, 77 
Salicylate of soda eruptions, 500 
Salicylic acid, eruption from, 500, 

501' 
Salipyrin eruptions, 502 
Salol eruptions, 502 
Sailor skin, 1000 
Santonin, eruption from, 502 
vSarcoid, multiple benign, 1033 
Sarcoma, arsenic injections in, 1032 
" capitis, 1027 

cutis, 1019 
" idiopathic multiple hemor- 

rhagic, 1028 



Sarcoma-like eruption caused by 
iodin, 505 
" melanotic, 1019 

multiple, 1023, 1024 

congenital, 1025 
" " of skin, see My- 

cosis, fun- 
goides, 1042 
" non-pigmented, 1022 

Sarcomatosis generalis, 1042 
Sarcoptes minor, 1368 

" scabiei communis, 1368 

Satyriasis, 900 

( Pathology, 1359 \ 

babies §££&,*& «5S 
( Treatment, 1365 ) 
animal, 1368, 1369 
" extensive in a leper, 1361 

Scales, definition of, 40 
Scar comedones, 1134 
Scars, atrophic, 44 
" definition, 43 
" hypertrophic, 44, 936 
" keloid, 44, 936 
Scheerende Flechte, 1379 
Scherlievo, 835 
Schmeerfluss, 1110 
Schuppen, 40 
Schuppenflechte, 354 
Sclerem der Neugeborenen, 640 
Sclerema adultorum, 615 

i Etiology, 641 ) 
ti neona- J Pathology, 642 f , 
torum J Diagnosis, 644 t ^ 
[ Treatment, 645 ) 
" of the new-born, 640 
Sclereme des adultes, 615 
Scleriasis, 615 
Sclerodactylia, 619 
Sclerodactylie, 619 
Sclerodermia, 615 

circum- ( Etiol °gy> 6 33 ) 
" scrrd,h atholo ^' 6 3| L 28 
6tc ) Diagnosis, 636 f 

5 ( Treatment, 639 ) 
" circumscribed, atrophy in, 630 
" bullae in, 632 

keloid in, 632 
" " ulceration in, 

" " in children, 622 

" " mixed, 615, 637 

41 " edematous form of, 

618 
" " pigmentation in, 617, 

620 



IXDEX. 



461 



Sclerodermia, diffuse symmetrical, 
Raynaud's disease and, 622 

Sclerodermia, diffuse symmetrical, 
subcutaneous nodules in, 618 

Sclerodermia, diffuse symmetrical, 
subcutaneous tubercles in, 618 

Sclerodermia neonatorum, 640 

Sclerodermic, 615 

Scleroma adultorum, 615 

Sclerostenosis, 615 

Scratched skin, description of, 42 

Scratching as a cause of skin disease, 

53 
Scrofulide boutonneuse benigne, 178 
" erythemateuse, 815 

tuberculeuse, 762 
Scrofulides nodulaires disseminees, 

1167 
Scrofulodermia, 806 

" ulcerative, 1042 

Scrofulo-gummata, 806, 807 
Scurf, 1 1 14 
Scurvy, land, 550 
Seasons as a cause of skin disease, 

5i 
Sebaceous cysts, 1124 
Sebaceous flux, 11 10 

" glands, diseases of the, 

1 1 10 
" glands, hypertrophy 

the, 1131 
Seborrhagia, 11 10 

I Etiology, 1115 
Pathology, 1115 I 
Diagnosis, 1117 1 
Treatment, 1118 ) 
cerea, mi 
congestiva, 815, 1115 
corporis, 1123 
eczemaformis, 1120 
furfuracea, 11 13 
general, 567 
lichenoides, 1123 
nasi, 1118 
nigricans, 1093 
oleosa, 1 no 
papulosa, 1 123 
pityriasiformis, 11 13 
psoriasiformis, 1123 
sicca, 1 11 1 
tabescentium, 1114 
Seborrheic dermatitis, n 19 

eczema, 1119, 1121 
wart, 577 
Seborrheid, eczemaform, 1120 
" papular, 1123 

•' psoriasiform, 1123 

Seborrheids, n 19 
Secondary lesions, 40 
Semeiology, 33 
Senile calvities, 1201 



Seborrhea 



of 



IIIO 



Senile struma, 807 

Sensory diseases, 714 

Serum eruptions, 118, 503 

Sewer-gas rash, 118 

Sex as a cause of skin disease, 55 

Sheep-pox, accidental inoculation of, 

519 

Shingles, 265 

Sibbens, 835 

Silver nitrate pigmentation: see 
Argyria, 671 

Simonea folliculorum, 1369 

Sivvens, 835 

Slate-colored pigmentation, 668 

Snake-poison and skin hemorrhages, 
552 

Soaps in the treatment of skin 
diseases, 84, 1419 

Soil as a cause of skin disease, 51 

Sommersprosse, 659 

Spargosis, 645 

Spas, 1412 

Special lesions, 44 

media in the treatment of 
skin diseases, 90 

Spedalskhed, 900 

Sphacelodermia, 527 

varieties of, 527 

Spherogyna ventricosa, 1368 

Spiradenitis suppurativa dissemi- 
nata, 1167 

Spitzcondylom, 578 

Spitzenwarze, 578 

Splenic fever, 573 

Spontaneous gangrene, 532 

of eyelids, 543 
keloid, 933 

Sporothrix, skin diseases due to, 1355 

Spots, 33 

Spotted sickness, 1335 

Squamae, definition of, 40 

Stains, 44 

Staining methods, 1406 

Staphylococci, the various, in dis- 
eases of the skin, 241 

Staphylococcus haemorrhagicus 
(Klein) in " gayle," 509 

Statistics of skin disease, 1399 

Stearrhea, n 10 

nigricans, 1093 

Steatoma, 1 r24 

Steatorrhea, 11 10 

Steatozoon folliculorum, 1369 

Stone pock, 1137 

Stramonium, eruption from, 502 

Streptococci in disease of the skin, 
241 

Streptothrix Madurae,i349, T 4°9 

Striae atrophica?, 698 

et maculae atrophica?, 698 

Strophulus, 1102 



1462 



INDEX. 



Strophulus, albidus, 11 29, 1130 

" prurigineux, 178 

Strychnia, eruption from, 502 
Sudamina, 1101 

" atrophica, 1106 

Sudatoria, 1087 
Sulphonal, eruption from, 502 
Sulphur in the treatment of skin 

eruptions, 80 
Summer prurigo, 348 
Superfluous hairs, treatment of, 1181 
Supernumerary nails, 1258 
Sweat glands, diseases of the, 1087 

tumors of the, 1 109 
Sweating and keratosis, 1089 
colored, 109S 
excessive, 1087 
" sickness, 10SS, 1103 

post-mortem, 1090 
Sycosis, 1237 

capillitii, 1245, note, 
coccogenic, 1236 
framboesiformis, 1243 
hyphogenic, 1236 
lupoid, 1238 
non-parasitaire, 1236 
nuchae necrotisans, 1243 
papillomateux, 1243 
parasitaire, 13 15 
parasitica (hyphogenic), 1315 
Symmetrical congestive mottling of 
the skin in rings, 107 
" gangrene, 528 

• ' purple congestion of the 

skin, 1026 
Symptomatic atrophy of the skin, 

'701 
Symptoms, general, 45 

objective, 33 
subjective, 48 
Syphilid, acneiform, 866 
" annular, 852 
bullous, 865 

congenital, 884 
" circinate, 852 
" corymbose, 862 
" ecthymatous, 867 
" eczemaform, 862 
" erythematous, 846 
" " congenital, 881 

" follicular, large, 857 
" " small, S61 

" frambesioid, 867 
" herpetiform, 863 
" lenticular, 856 
" lichenoid, 857 
" macular, 847 
*' nodular, 868 
*' " congenital, 885 

" nummular, 850 
iS orbicular, 852 



Syphilid, palmar, 853 

late, squamous, 875 
papular, 849 

large, 850, 856 
small, congenital, 
883 
" papulosquamous, 950 
" " " congeni- 

tal, 883 
" pemphigoid, 866 
" " congenital, 884 

*' pigmentary, 872 
" plantar, 853 
" pustular, 862 

small, 866 
" rupia, S64 
". squamaus, 850 
" tubercular, 868 
" " congenital, 885 

" varicelliform, 864 
" varioliform, 864 
" vesicular, 862, 863 
" " congenital, 8S3 

" " large, 863 

" " small vesicular 

eczematous, 
863 
Syphilids, anatomy of, 845 

classification of, 842 
general characters of, 843 
" pathology, 845 

" secondary, 843 

41 tertiary, 844 

" treatment, general, 886 

local, 897 
of congenital, 
899 
Syphilis, acquired, 835 

" " in children, 877 

" congenital, 878 

" cutaneous manifestations 

of, 842, 843 
" Larrieu's method of treat- 

ment of, 896 
" malignant, 841 

" of mucous membranes, S70 

" pigmentary change in, 872 

purpura in, 875 
" pyrexia in, 836 

" tables of the course and 

stages of acquired, 838, 
839, 840, 841 
" treatment of, 886 

" " "in children, 

899 
" " " intravenous 

injection in 
the, 892 
" yaws and, 1065 

Syphilitic alopecia, 876 

exanthem, 846 



INDEX. 



i 4 tr 



Syhilitic gummata, 869 
impetigo, S67 
" keloid, 933 

" lesions oi mucous mem- 

branes, congenital, 882 
" leukodermia, 874 

" lupus, S69 

" nail affections, 877 

nodules, 869 
perionychia, 877 
" phagedena, 872 

" psoriasis, 850 

44 purpura, 875 

" roseola, S46 

44 congenital, 881 
" ulceration, 871 

vitiligo, 874, note. 
Syphiloderma circinatum, 852 

" papulo-squamosum, 

§59 
p a p u 1 o-squamosum 
congenital, 882 
Syringadenoma, 978 
Syringocystadenoma, 978 

cystoma, 978 
Syringoma, 978 
Syringon^elia, 707 



Tache de feu, 962 
Taches, 33 

44 ombrees, 1382 
Tannin, eruption from, 503 
Tar, eruption from, 503 

" externally in the treatment of 

eczema, 226 
44 externally in the treatment of 

psoriasis, 387 
" internally in the treatment of 
skin diseases, 80 
Tartar emetic eruptions, 462 
Tartarus boraxatus eruption, 477 
Tattooing, 672 
Teigne faveuse, 1265 
tondante, 1279 
" tonsurante, 1279 
Telangiectases, 34 

" caused by X-rays, 968 

Telangiectasie verruqueuse, 612 
Telangiectasis, 967 

follicularis annulata, 
972, note. 
Telangiectic lupus erythematosus, 
819 
" warts. 612 

Terebene, eruption from, 502 
Thiol in the treatment of skin dis- 
eases, 81 
Thiosinamin, formula for, injection, 
1439 



Thiosinamin in keloid, 942 

Thyroid gland in treatment of lupus 

vulgaris, 783 
Thyroid gland in treatment of skin 

diseases, 78 
Tina, 1335 

Tinea amiantacea, 11 10 
" asbestina, 11 10 
44 axillaris, 1313 
44 barbae, 13 15 
44 ciliorum, 1320 
44 circinata, 1309 

concentric rings in, 

1311 
examination of fungi, 

1409 
megalosporon form 
of, 1312 
44 microsporon f orm of , 

■ 1309 

of palms and soles, 
1315 
" " treatment of, 1296 

44 tropica, 1312 

44 cruris seu axillaris, 1313 
44 decalvans, 1209 
44 favosa, 1265 
44 imbricata, 1323 
44 lupinosa, 1265 
44 nodosa, 1 176 
" sycosis, 1288, 1315 

44 fungus in, 1288, 1318 
44 tondens, 1279 

f Etiology, 1291 "] 
44 tonsu- J Pathology, 1280 I 

rans ] Diagnosis, 1294 ( I2 ' 9 
[Treatment, 1296J 
44 tonsurans, bald form of, 1284 
fungi of, 1280, 1409 
44 " in fair children, 

1293 
" tricophytina, 1279 
44 tropica, 1289, 1312 
44 ungiiium, 1252, 1322 

fungi in, 1288, 1305 
44 44 treatment of, 1307 

44 varieties of, 1279 
44 vera, 1265 
" versicolor, 1327 
44 44 head and face and 

limbs, 1328 
44 44 in childhood, 1329 

44 44 " colored races, 

1329 
Tokelau ringworm. 1323 
Tondante peladoide, 1286 
Tonga, 1057 

Toxicodendron dermatitis, 465 
Toxins, 65 

Toxins (anti-toxins), eruptions due to 
the injection of, 503 



1464 



INDEX. 



Toxi-tuberculidespapulo-necrotiques, 

1167 
Traumaticin, 1429 
Treatment, general, 72 
" internal, 72 

" local, 83 

Trichauxis, 11 79 
Trichiasis, 1180 
Trichoclasis, 1188 

Trichomycose nodulaire, 11 76, 7iote. 
Trichomycosis nodosa, 11 71 

palmellina, 11 71 
Trichonosis cana, 1193 

" discolor, 1193 

" furfuracea, 1279 

Trichophytiasis, primary, of the 

mouth, 1291 
Trichophytie circinee, 1309 

sycosique, 1315 
Trichophyton megalosporon ecto- 
thrix, 1287 
" megalosporon, endo- 

thrix, 1285 
Trichophyton microsporon, 1281 
Trichoptilimania, 1161 
Trichoptilois, 1188 
Trichorrhexis nodosa, 1188 
Trombidion soyeux, 1372 
Trombidium autumnale, 1372 
holosericum, 1372 
Trophedema, chronic hereditary, 650 
Tropical phadenic ulcer, 544 
Trypoderma, 1387, note. 
Tsetse fly, 1386 
Tubercles, definition of, 36 
Tubercular disease of the foot, 1346 
Tuberculides, 1167 

" acneiformes et necro- 

tiques, 1167 
Tuberculin, eruptions from, 118, 503 
in the treatment of lupus 
vulgaris, 784 
" injections as a cause of 

chilblains, 11 1, note. 
Tuberculosis bacillus, 1410 
" of the skin, 759 

" " ' miliary, 803 

" " " " chronic, 

804 
" verrucosa cutis, 797, 798, 

799 
Tuberculous folliculitis, 1248 
*' tumors, 808 

" ulcer of the skin, acute, 

804 
" ulcers, 805 

Tuberculum sebaceum, 1129 
Tumenol in the treatment of skin 

diseases, 81 
Tumeurs d'emblee in mycosis fun- 
goides, 105 1 



Tumores, 37 
Tumors, 37 

of the sweat glands, 1109 
" pendulous, 947 
Turban tumors, 1027 
Turpentine, eruptions from, 462, 504 
in the treatment of pso- 
riasis, 383 
in the treatment of skin 
eruptions, 79 
Tyloma, 586 
Tylosis, 586, 587 

" of nail-matrix, 1257 
" palmse et plantae, 587 

manus from arsenic, 
588 

" verrucosa, 588 
" produced by sweating, 588 



U 



Ulcer, definition of, 43 

" perforating, of the foot, 705 
tuberculous, of skin, acute, 804 
Ulcerative scrofuloderma, 1042 
Ulcerating granuloma of the pu- 
denda, 1076 
Ulcere chancreux. 1009 

" rongeant, 1009 
Ulcus exedens, 1009 

grave, 1346 
Ulerythema ophryogenes, 1203, 1234 

" sycosiforme, 1236 

Uncleanliness as a cause of disease, 52 
Unilateral atrophy of the face. 637 

sweating, 1088 
Uremic erythema, 60 
Uridrosis, 1099 

Urine in diseases of the skin, 61 
Urticaire, 155 

f Varieties, 156, 157' 
I Etiology. 163 
Urticaria \ Pathology, 166 ^155 
I Diagnosis, 177 
L Treatment, 168 
" acuta, 160 

" blood in, 167 

bullosa. 157 
" chronica, 161 

" factitia, 159 

" febrilis, 160 

•* from hydatids, 164 

" from mental emotion, 

165 
" gigans. 156 

" hemorrhagica, 157 

" in children, 158 

" internal hemorrhages in, 

157 
" mucous membranes af- 

fected in, 156, 157 



INDEX. 



1465 



Urticaria cedematosa, 156 

" papulosa, 156, 158 

" persistent nodules in, 

161 
" perstans, 161 

" " tuberosa, 162 

c< " verrucosa, 162 

" pigmentation after, 162, 

171 

f Varieties, 172 ] 
pig- I Etiology, 172 
" men- ■{ Pathology, 175 J- 171 
tosa j Diagnosis, 167 
[Treatment, 177 
" " after vaccination, 523 
" pigmentosa, forms of, 172 
" " variations in, 

173 
" " white cicatri- 

ces in, 173 
subcutanea, 157 
tuberosa, 156 
" white cicatrix in, 163 
Urticarial eruptions, drugs causing, 
505 



Vaccination, accidental, 518 

antisepticism in, 517 
as a cause of skin dis- 
ease, 56 
auto-inoculation in, 520 
botryomycosis after, 

526 
bullous eruption after, 

521 
cellulitis after, 525 
dermatitis herpeti- 
formis after, 524 
eczema after, 523 
eruptions, classification 

of, 517 
erysipelas, after, 525 
erythema exudativum 

after, 523 
furunculosis after, 525 
gangrene, 526 

" disseminated, 

526 
" local, 526 
granuloma after, 526 
hemorrhagic, 523 
hirsuties after, 524 
impetigo contagiosa 

after, 525 
keloid after, 524 
leprosy after, 525 
lupus vulgaris after, 

525 
on nevi, 964 



Vaccination, papular eruptions after, 
521 
" papulo-vesicular erup- 

tions after, 521 
pemphigus after, 524 
" psoriasis after, 523 

pustular eruptions 
after, 521 
" pyaemia after, 525 

rashes, 516 
recrudescence of, 519 
roseola after, 521 
secondary inoculation 

in, 518 
septic conditions after, 

525 
syphilis after, 525 
ulceration after, 526 
" urticaria after, 523 

" pigmentosa 
as a squelof, 
523 
vesicular eruptions, 521 
Vaccinia, generalized, 519 
Vaccine generalisee, 579 

lichen, 521 
Vagabond's disease, 664, 1379 
Varicella gangrenosa, 535 
prurigo, 522, 538 
Varnishes, formulae for, 1429 

" in the treatment of skin 

diseases, 91 
Varus, 1 136 

Vascular dilatations, acquired, 967 
Vaso-motor centers, 47 
Vegetable parasitic diseases, 1264 
Vegetations veneriennes, 578 
" vasculaires, 986 

Veld sore, 1070, 1075 
Vendangeur, 1372 
Venereal wart, 57S 
Venous nevus, 963 
Ver macaque, 1387 
Verruca, 575 

" acuminata, 578 

" contagion as a cause of, 579 

digitata, 578 
" filiformis. 578 
" necrogenica, 797, 799 
" " identical with 

the lupus ver- 
rucosus, 797 
" plana, 576 

seniorum, 577 
" plantaris, 575 
" seborrhoica, 577 
" senilis, 577 
" vulgaris, 575 
Verrucas planae juveniles, 576 
Verrue, 575 
Vermes charnues, 944 



14^)6 



INDEX. 



Verruga Peruana, 1067 
Vesicles, definition of, 37 
Vesiculse, " " 37 

Vesicular eruptions, drugs causing, 

504 
Vi bices, definition of, 34, 549 
Vitiligo, 675 

of Bateman, 700 
" Willan, 700 
.Vitiligoidea, 737 

W 

Wadding as a preventive of urticaria, 

170 
Wart, 575 

" peruvian, 1067 
plantar, 575 

" seborrhoic, 577 

" soft, 944 

telangiectic, 612 
Warts, contagiousness of, 579 
Warze. 575 

Waters; natural mineral, 1410 
Wen, 1 1 24 

AVerlhof's disease, 550 
Wheals, anatomy of, 166 
definition of, 39 
White leprosy, 673 

" moles, 959 

" nails, 1256 
Whiteness of the hair, 1193 
Whitlow, analgesic paralysis with, 

707 

melanotic, 1021 
AVolossatik, 1383 
Wood ticks, 1371 

X 

X-ray telangiectases, 968 

X-rays in treatment of skin diseases, 

93/789. 943, 9&r, "85 
Xanthelasma, 737 
Xanthelasmoidea, 171 
Xanthochromia, 744 

( Etiology, 743 ) 

Xanthoma 1 Pathology, 744 



Xanthoma, diabeticorum, without 

*' diabetes, 756 

" elasticum, 747 

" hereditary, 743 

" in children, 740 

" involution in, 749 

" jaundice as a cause of, 744 

" lineare, 739 

" maculatum, 739 

" multiplex, 739 

" nodules in, 738 

'.' of mucous membranes, 740, 
742 

" palpebrarum, 738 

" papulatum, 739 

" planum, 738 

" simulated by dermoid cysts, 
748 

" striatum, 739 

" tuberculatum, 739 

" tuberosum, 739 

" urticaria pigmentosa, mis- 
taken for, 749 

" ichthyoides, 559 
Xerodermia, 560 



Etiology, 686 ) 
Pathology 687 ( 68l 

tosa S»««!":"?. 



P*g 

men 



Treatment, 691 
pigmentosa and hydroa 
aestivalis, 690 
and hydroa vaccini- 
formis, 345 



Yaws 



1057 



j Diagnosis, 748 
( Trek 



737 



-eatment, 750 ; 

( Etiology, 752 ) 

«, diabeti- J Pathology, 752 f 

corum J Diagnosis, 754 C '^° 

(. Treatment, 755 ) 



( Etiology, 1062 
J Pathology, 1062 
] Diagnosis, 1064 
( Treatment, 1065 
and syphilis, 1065 
ringworm, 1060 



Ziehl-Neelsen method of staining, 

1408 
Zona, 265 
Zoster, 271 

1 ' atypicus gangrsenosus et hys- 
tericus" 534 



Catalogue of the Medical, Dental, Phar- 
maceutical, Chemical, and Scientific Books 
Published by P. Blakiston's Son & Co., 
1012 Walnut Street, Philadelphia. 

Established 1843. 

SPECIAL NOTE. 



The prices as given in this catalogue are absolutely net — no discount will be 
allowed retail purchasers under any consideration. This rule has been established 
in order that every one will be treated alike, a general reduction in former prices 
having been made to meet previous retail discounts. Upon receipt of the adver- 
tised price any book will be forwarded by mail or express, all charges prepaid. 



We keep a large stock of Miscellaneous Books relating to Medicine and 
Allied Sciences, published in this country and abroad. Inquiries in regard to 
prices, date of edition, etc. , will receive prompt attention. 



CATALOGUES AND CIRCULARS SENT FREE UPON APPLICATION: 

Catalogue No. 1. — A complete list of the titles of all our publications on Medicine, Dentistry, 
Pharmacy, and Allied Sciences, with Classified Index. 

Catalogue No. 3. — Pharmaceutical Books. 

Catalogue No. 4. — Books on Chemistry and Chemical Technology. 

Catalogue No. 5. — Books for Nurses and Lay Readers. 

Catalogue No. 6. — Books on Dentistry and Books used by Dental Students. 

Catalogue No. 7. — Books on Hygiene and Sanitary Science ; Including Water and Milk 
Analysis, Microscopy, Physical Education, Hospitals, etc. 

Catalogue No. 8. — List of about 300 Standard Books classified by Subjects. 

Catalogue No. 9. — Books on Nervous and Mental Diseases. 

Catalogue No. 10. — Books on Diseases of the Eye, Refraction, Spectacles, etc. 

A Gervera.1 Catalogue. — Containing 2000 titles of Standard Books on Medicine and Sur- 
gery. American and English. 

Special Circulars. — Morris' Anatomy; Gould and Pyle's Cyclopedia; Deaver's Surgical 
Anatomy; Tyson's Practice ; Gould's Medical Dictionaries; Books on 
the Eye ; Books on Diseases of the Nervous System ; The ? Quiz- 
Compend? Series, Visiting Lists, etc. We can also furnish sample 
pages of most of our publications. 



P. Blakiston's Son S, Co.'s publications may be had through the booksellers in all 
the principal cities of the United States and Canada, or any book will be sent, postpaid, upon receipt 
of the price. Special terms of payment will be allowed to those of approved credit. No discount 
can be allowed retail purchasers under any circumstances. Money should be remitted by express 
or post-office money order, registered letter, or bank draft. 



THE PRICES OF ALL BOOKS ARE NET. 



CLASSIFIED LIST, WITH PRICES, 

OF ALL BOOKS PUBLISHED BY 
P. BLAKISTON'S SON & CO., PHILADELPHIA. 

When the price is not given below, the book is out of print or about to be published. 
Cloth binding, unless otherwise specified. For full descriptions see following Catalogue. 



Analysis. Vol. I 



4.5o 
3-5o 
3-5o 



ANATOMY. 
Ballou, Veterinary Anat. $0.80 
Broomell. Anatomy and 

Histol. of Mouth and Teeth. 4.50 
Campbell. Dissection Out- 
lines. .50 

Deaver. Surgical Anatomy. 21.00 
Gordinier. Anatomy of Nerv- 
ous System. Illustrated. 6.00 
Heath. Practical. 7th Ed. 4.25 
Holden. Dissector. 2 Vols. 3 00 

Osteology. 8th Ed. 5.25 

Landmarks. 4th Ed. .75 

Hughes. Dissector. Part I. 3.00 

Part II. - - 3.00 

Part III. - - 3.00 

Macalister's Text-Book. - 5.00 

McMurrich. Embryology. 

Minot. Embryology. - 

Marshall's Phys. & Anatom- 
ical Diagrams. $40.00 and 60.00 
Morris. Text-Book Anat. New 

Ed. 846 111. Clo., $6.00; Sh., 7.00 
Potter. Compend of. 6th 

Ed. 133 Illustrations. - .80 

Wilson's Anatomy, nth Ed. 5.00 

ANESTHETICS. 
Buxton. Anesthetics. - 1.50 

Turnbull. 4th Ed. - 2.50 

BACTERIOLOGY. 
Conn. Agricultural Bacteri- 
ology. Illustrated. - - 2.50 

Bact. in Milk Products. 

Emery. Bacteriolog. Diag. 1.50 
Hewlett. Manual of. Illus. 4.00 
Williams. Student's Manual 

of. 2d Edition, go Illus. 1.50 

BRAIN AND INSANITY. 
Blackburn. Autopsies. - 1.25 
Chase. General Paresis. 1.75 

Horsley. Brain and Sp. Cord. 2.50 
Ireland. Mental Affections 

of Children. - - - 4.00 
Lewis. Mental Diseases. 7.00 
Mann's Psychological Med. 3.00 
Regis. Mental Medicine. - 2.00 
Stearns. Mental Dis. Illus. 2.75 I 
Tuke. Dictionary of Psycho- 
logical Medicine. 2 Vols. 10.00 j 
Wood. Brain and Overwork. .40 

CHEMISTRY. 

Technol'g'lBooks, Water, Milk, etc. 
Allen. Commercial Organic 



Vol. II. Part I. 

Vol.11. Part II. 

Vol. II. Part III. 

Vol. III. Part I. - 4-50 

Vol. III. Part II. - 4.50 

Vol. III. Part III.- 4.50 

Vol. IV. - - - 4.50 

Bailey and Cady. Chem. 

Analysis.- - - - 1.25 
Bartley. Medical Chemistry. 3.00 

Clinical Chemistry. 1.00 

Bloxam's Text-Book. 9th Ed. 

Bunge. Physiologic and Path- 
ologic Chemistry. - - 3.00 

Caldwell. Qualitative and 

Quantitative Analysis. - 1.00 
Cameron. Oils & Varnishes. 2.25 

■ Soap and Candles. - 2.00 

Clowes and Coleman. Quan- 
titative Analysis. 5th Ed. - 3.50 
Coblentz. Volumetric Anal. 1.25 
Congdon. Laboratory. - 1.00 
Gardner. Brewing, etc. - 1.50 
Gray. Physics. Vol. I. - 4.50 
Groves and Thorp. Chemi- 
cal Technology. Vol. I. Fuels 5.00 

. Vol. II. Lighting. - 4.00 

Vol. III. Gas Lighting. 3.50 

Vol. IV. Elec. Lighting. 

Heusler. The Terpenes. 4.00 



Holland. Urine, Gastric Con- 
tents, Poisons and Milk Anal- 
ysis. 6th Ed. - - - $1.00 

Leffmann's Medical Chem. .80 

Food Analysis. - - 2.50 

Milk Analysis. - - 1.25 

Water Analysis. - 1.25 

Structural Formulae. 1.00 

Muter. Pract. and Anal. 1.25 

Oettel. Electro-Chem. - .75 

Electro-Chem. Exper.- .75 

Richter's Inorganic. 5th Ed. 1.75 
Organic. 3d Ed. 2 Vols. 

Vol. I. Aliphatic Series. 3.00 
Vol.11. Carbocyclic " 3.00 
Rockwood. Chemical Anal. 1.50 
Smith. Electro-Chem. Anal. 1.25 
Smith and Keller. Experi- 
ments. 4th Ed. Illus. .60 
Sutton. VolumetricAnal. 5.00 
Symonds. Manual of. 2.00 
Traube. Physico-Chem.Meth. 1.50 
Thresh. Water Supplies. - 2.00 
Ulzer and Fraenkel. Tech- 
nical Chemical Analysis. 1.25 
Woody. Essentials of. 4th Ed. 1.50 

CHILDREN. 
Hatfield. Compend of. .80 

Power. Surgical Diseases of. 2.50 
Smith. Wasting Diseases of. 2.00 
Starr. Digestive Organs of. 3.00 

Hygiene of the Nursery.1.00 

Taylor and Wells. Manual. 4.50 

CLINICAL CHARTS, ETC. 
Griffith's Temp't're Charts. 

Pads of 50 - . - .50 

Keen. Outline Drawings of 

Human Body. Pads. - .25 

Schreiner. Diet Lists. Pads, .75 

COMPENDS. 

Ballou. Veterinary Anat. .80 

Brubaker's Physiol. 10th Ed. .80 

Cushing. Histology. - - .80 

Gould and Pyle. The Eye. .80 

Hatfield. Children. - .80 

Horwitz. Surgery. 5th Ed. .80 

Hughes. Practice. 2 Pts. Ea. .80 

Landis. Obstetrics. 7th Ed. .80 

Leffmann's Chemistry. 4th Ed. .80 

Potter's Anatomy, 6th Ed. .80 

Materia Medica. 6th Ed. .80 

Schamberg. Skin Diseases. . .80 

Stewart. Pharmacy. 5th Ed. .80 

Thayer. General Pathology. .80 

Special Pathology. .80 

Warren. Dentistry. 3d Ed .80 

Wells. Gynecology. 2d Ed. .80 

Any of above, Interleaved, $1.00. 
Self- Examination. 3500 

Questions on Medical Sub- 
jects. - - Paper, .10 

CONSUMPTION. 
Knopf. Pulmon. Tuberculosis. 3.00 
Steell. Physical Signs of Pul- 
monary Disease. ... 1.25 

DENTISTRY. 
Barrett. Dental Surg. - 1.00 

Broomell. Anat. and Hist, of 

Mouth and Teeth. - - 4.50 
Fillebrown. Op. Dent. Illus. 2.25 
Gorgas. Dental Medicine. 4.00 

Questions and Answers. 6.00 

Harris. Principles and Prac. 6.00 

Dictionary of. 6th Ed. 5.00 

Richardson. Mech. Dent. 5.00 

Smith. Dental Metallurgy. 

Taft. Index of Dental Lit. 2.00 
Tomes. Dental Surgery. 
Dental Anatomy. 



4.00 

4.00 

.80 



Warren's Compend of. 

Dental Prosthesis and 

Metallurgy. Illus. - 1.25 

White. Mouth and Teeth. .40 



DIAGNOSIS. 

Brown. Medical. 4th Ed. $2.25 

Tyson's Manual. 4th Ed. Illus. 1.50 
DICTIONARIES, ETC. 

Gould's Illustrated Dictionary 
of Medicine, Biology, and Al- 
lied Sciences, etc. 5th Edi- 
tion. Leather, $10.00; Halt 
Russia, Thumb Index, - 12 00 

Gould'sStudent's Medical Dic- 
tionary, nth Ed., Illus., % 
Mor., $2.50; Thumb Ind., 3.00 

Gould's Pocket Dictionary — 
30,000 medical words. 4th 
Edition. Enlarged. Leather, 1.00 

Gould and Pyle. Cyclopedia 
of Med. and Surg. One Vol. 
Illus. Leather, 10.00 

Gould and Pyle's Pocket 
Cyclopedia of Medicine. 1.00 

Harris' Dental. Clo. 5.00; Shp. 6.co 

Longley's Pronouncing. .75 

Maxwell. Terminologia Med- 
ica Polyglotta. - - 3.00 

Treves. German-English. 3.25 

EAR. 
Burnett. Hearing, etc. .40 

Hovell. Treatise on. - 5.50 

Pritchard. Diseasesof. 3d Ed. 1.50 

ELECTRICITY. 
Bigelow. Plain Talks on. 1.00 
Hedley. Therapeutic Elec. 2.50 
Jacobi. Electrotherapy. 2V0IS. 5.00 
Jones. Medical Electricity. 3.00 

EYE. 
Donders. Refraction. - 1.25 

Fick. Diseases of the Eye. 4.50 
Gould and Pyle. Compend. .80 
Greeff. Microscopic Examin- 
ation of. - - - - 1.25 
Harlan. Eyesight. - .40 

Hartridge. Refraction. 1 1 th Ed . 1 . 50 

Ophthalmoscope. 4th Ed. 1.50 

Hansell and Reber. Mus- 
cular Anomalies of the Eye. 1.50 
Hansell and Bell. Clinical 

Ophthalmology. 120 Illus. 1.50 
Jennings. Ophthalmoscopy. 1.50 
Morton. Refraction. 6th Ed. 1.00 
Ohlemann. Ocular Therap. 1.75 
Parsons. Optics. - - 2.00 
Phillips. Spectacles and Eye- 
glasses. 49 Illus. 2d Ed. 1.00 
Swanzy's Handbook. 7th Ed. 2.50 
Thorington. Retinoscopy. 1.00 

Refraction. 200 Illus. 1.50 

Walker. Student's Aid. 1.50 

"Wright. Ophthalmology. 3.00 

GYNECOLOGY. 

Bishop. Uterine Fibromyo- 
mata. Illustrated. - - 3.50 

Byford (H. T.). Manual. 3d 
Edition. 363 Illustrations. 3.00 

Diihrssen. Gynecological 

Practice. 105 Illustrations. 1.50 

Lewers. Dis. of Women. 2.50 

Montgomery. Text -book 
of. 527 Illus. - 5.00 

Roberts. Gynecological Path- 
ology. Illustrated. - 6.00 

Wells. Compend. Illus. .80 

HEALTH AND DOMESTIC 
MEDICINE. 
Bulkley. The Skin. - .40 

Burnett. Hearing. - .40 

Cohen. Throat and Voice. .40 
Dulles. Emergencies. 5th Ed. 1.00 
Harlan. Eyesight. - .40 

Hartshorne. Our Homes. .40 
Osgood. Dangers of Winter. .40 
Packard. Sea Air, etc. .40 

Richardson's Long Life. .40 

"White. Mouth and Teeth. .40 
Wilson. Summer and its Dis. .40 



CLASSIFIED LIST OF P. BLAKISTON'S SON &+ CO.'S PUBLICATIONS. 



2.O0 

.40 
2.5O 
7.OO 

3 00 
1.25 

2.00 



HISTOLOGY. 
Cushing. Compend. - - $0.80 
Stirling. Histology. 2d Ed. 2.00 
Stohr's Histology. Illus. - 3.00 

HYGIENE. 

Canfield. Hygiene of the Sick - 
Room. .--- 1.25 

Coplin. Practical Hygiene. 

Kenwood. Public Health 
Laboratory Guide. 

Lincoln. School Hygiene. 

McFarland. Prophylaxis. 

Notter. Practical Hygiene. 

Parkes' (L. C), Manual. 

Elements of Health. 

Rosenau. Disinfection and 

Disinfectants. Illus. 

Starr. Hygiene of the Nursery. 1.00 

Stevenson and Murphy. A 

Treatise on Hygiene. In 3 

Vols. Circular Vol. I, 6.00 

upon application. Vol. II, 6.00 

Vol. Ill, 5.00 

Thresh. Water Supplies. 2.00 

Wilson's Handbook. 8th Ed. 3.00 

Weyl. Coal-Tar Colors, 1.25 

MASSAGE, ETC. 

Mitchell and Gulick. Me- 
chanotherapy. Illustrated. 2.50 
Ostrom. Massage. 115 Illus. 1.00 

MATERIA MEDICA. 

Biddle. 13th Ed. Cloth, 

Bracken. Materia Med. 2.75 

Coblentz. Newer Remedies. 1.00 
Davis. Essentials of. - 1.50 

Gorgas. Dental. 5th Ed. 4.00 
Groff. Mat. Med. for Nurses. i.*5 
Heller. Essentials of. - 1.50 

Potter's Compend of. 6th Ed. .80 
Potter's Handbook of. 9th 

Ed. Cloth, $5.00 ; Sheep, 6.00 
Sayre. Organic Materia Med. 

and Pharmacognosy. - 4.50 
Tavera. Medicinal Plants of 

the Philippines. - - 2.00 
White and Wilcox. Mat. 
Med., Pharmacy, Pharmacol- 
ogy, and Therapeutics. 5th 
Ed. Enlarged. CI. ,$3.00; Sh. 3.50 

MEDICAL JURISPRUDENCE. 

Mann. Forensic Med. - 6.50 
Reese. Med. Jurisprudence and 
Toxicology. 5th Ed. $3.00; Sh. 3.50 

MICROSCOPE. 
Carpenter. The Microscope. 

8th Ed. 850 Illus. - 8.00 

Lee. Vade Mecum of. 5th Ed. 4.00 

Oertel. Med. Microscopy. 

Reeves. Med. Microscopy. 2.50 
Wethered. Medical Micros- 
copy. Illus. ... 2.00 

MISCELLANEOUS. 
Black. Micro-organisms. 
Burnet. Food and Dietaries. 
Cohen. Organotherapy. • 
Da Costa. Hematology. - 
Davis. Alimentotherapy. 
Goodall and Washbourn. 

Infectious Diseases. Illus. 
Gould. Borderland Studies. 
Greene. Medical Examination 

in Life Insurance. Illus. - 4.00 
Haig. Uric Acid. 5th Ed. 3.00 

Diet and Food. 3d. Ed. 1.00 

Hare. Mediastinal Disease. 2.00 
Hemmeter. Diseases of Stom- 
ach. 2d Edition. Illus. - 6.00 

Diseases of Intestines. 

Illustrated. 2 Vols. - 10.00 

Henry. Anaemia. - - .50 
McCook. Amer. Spiders. 40.00 
New Sydenham Society's 

Publications, each year. - 8.00 
Schofield. The Force of Mind. 2.00 
Thorne. Schott Methods in 

Heart Disease. - - 2.00 

Tissier. Pneumatotherapy. 2.50 
Treves. Physical Education 
Weber and Hinsdale. Cli 

mate. 2 Vols. Illustrated. 
Winternitz. Hydrotherapy, 



•75 
1.50 

2.50 
5.00 
2.50 

3.00 
2.00 



75 



5.00 
2.50 



NERVOUS DISEASES, ETC. 

Dercum. Rest, Mental Thera- 
peutics, Suggestion. - $2.50 

Gordinier. Anatomy of Cen- 
tral Nervous System. - 6.00 

Gowers. Manual of. 530 Illus. 
Vol. I, $4. 00; Vol.11, - 4.00 

Syphilis and the Ner- 
vous System. ... 1.00 

Epilepsy. New Ed. 3.00 

Ormerod. Manual of. - 1.00 
Pershing. Diagnosis of Nerv. 

and Mental Diseases. - 1.25 
Preston. Hysteria. Illus. 2.00 

NURSING. 

Canfield. Hygiene of the Sick- 

Room. .... 1.25 
Cuff. Lectures on. 3d Ed. 1.25 
Davis. Bandaging. Illus. 1.50 
Domville's Manual. 8th Ed. .75 
Fullerton. Obst. Nursing. 1.00 

Surgical Nursing. 1.00 

Gould. Pocket Medical Dic- 
tionary. Limp Morocco. 1.00 

Groff. Mat. Med. for Nurses. 1.25 
Hadley. Manual of. - 1.25 
Humphrey. Manual. 23d Ed. 1. 00 
Starr. Hygiene of the Nursery. 1.00 
Temperature Charts. Pads. .50 
Voswinkel. Surg. Nursing. 1.00 

OBSTETRICS. 
Cazeauxand Tarnier. Text- 
Book of. Colored Plates. 4.50 

Edgar. Text-book of. - 

Landis. Compend. 6th Ed. .80 
Winckel's Text-book. 5.00 

PATHOLOGY. 
Barlow. General Pathology. 5.00 
Blackburn. Autopsies. 1.25 
Coplin. Manual of. 3d Ed. 3.50 
Da Costa. The Blood. - 5.00 
Roberts. Gynecological Path- 
ology. Illustrated. - 6.00 
Thayer. General Pathology .80 

Special Pathology. .80 

Virchow. Post-mortems. .75 

Whitacre. Lab. Text-book. 1.50 

PHARMACY. 
Beasley's Receipt-Book. - 2.00 

Formulary. - - 2.00 

Coblentz. Manual of Pharm. 3.50 
Proctor. Practical Pharm. 3.00 
Robinson. Latin Grammar of. 1.75 
Sayre. Organic Materia Med. 

and Pharmacognosy. 2d Ed. 4.50 
Scoville. Compounding. 2.50 

Stewart's Compend. 5th Ed. .80 
U. S. Pharmacopoeia. 7th 

Revision. 1890 CI. $2.50; Sh., 3.00 

Postage extra, .27 

Select Tables from U. S. P. .25 

PHYSIOLOGY. 

Birch. Practical Physiology. 1.75 
Brubaker's Compend. 10th Ed. .80 
Jones. Outlines of. - - 1.50 
Kirkes' New 17th Ed. (Halli- 
burton.) Cloth, $3.00; Sh., 3.75 

Lsvndois' Text-book. 845 Illus. 

Starling. Elements of. - 1.00 
Stirling. Practical Phys. 2.00 
Tyson's Cell Doctrine. - 1.50 

POISONS. 

Reese. Toxicology. 4th Ed. 3.00 
Tanner. Memoranda of. .75 

PRACTICE. 
Beale. Slight Ailments. 1.25 

Fagge. Practice. Vol. I, 6.00 

Vol.11, 

Fowler's Dictionary of. - 3.00 
Gould and Pyle. Cyclopedia 

of Medicine. Illustrated. 10.00 
Hughes. Compend. 2 Pts. ea. .80 

Physician's Edition. 

1 Vol. Morocco, Gilt edge. 2.25 
Taylor's Manual of. 6th Ed. 4.00 
Tyson. The Practice of Medi- 
cine. Illus. CI. £5.50; Sheep 6.50 



SKIN. 

Bulkley. The Skin. - go. 40 
Crocker. Dis. of Skin. Illus. 5.00 
Schamberg. Compend. .80 

Van Harlingen. Diagnosis 

and Treatment of Skin Dis. 

3d Ed. 60 Illus. - - 2.75 



SURGERY AND SURGICAL 
DISEASES. 

Berry. Thyroid Gland. - 4.00 
Butlin. Surgery of Malignant 

Disease. - - - 4.50 

Davis. Bandaging. Illus. 1.50 
Deaver. Appendicitis. - 5.30 

Surgical Anatomy. - 21.00 

Dulles. Emergencies. - 1.00 
Hamilton. Tumors. 3d Ed. 1.25 
Heath's Minor. 12th Ed. 1.50 

Clinical Lectures. - 2.00 

Horwitz. Compend. 5th Ed. .80 
Jacobson. Operations of. - 10.00 
Keay. Gall-Stone Disease. 1.25 
Kehr, Gall-StoneDisease - 2.50 
Macready on Ruptures - 6.00 
Makins. Surgical Experi- 
ences in South Africa. - 4.00 
Maylard. Surgery of the Ali- 
mentary Canal. - - 3.00 
Morris. Renal Surgery. 2.00 

Moullin. Complete Text- 
book. 3d Ed. by Hamilton. 
600 Illustrations. - - 6.00 
Smith. Abdominal Surg. 10.00 
Voswinkel. Surg. Nursing.- 1.00 
Walsham. Surgery. 7th Ed. 3.50 



THERAPEUTICS. 

Beasley's 3000 Prescriptions. 2.00 
Biddle. Materia Medica and 

Therapeutics. 13th Edition. — — 
Coblentz. New Remedies. 1.00 
Cohen. Physiologic Thera- 
peutics. 11 Volumes. 27.50 
Mays. Theine. - - .50 
Murray. Notes on Remedies. 1.25 
Potter's Compend. 6th Ed. .80 

Handbook of Mat. Med. 

Phar. and Thera. 9th Ed. 5.00 
White and Wilcox. Mat. 
Med., Pharmacy, Pharmacol- 
ogy, and Therap. 5th Ed. 3.00 



THROAT AND NOSE. 

Cohen. Throat and Voice. .40 
Hall. Nose and Throat. - 2.75 
Hollopeter. Hay Fever. 1.00 

Knight. Throat. Illus. - 

Lake. Laryngeal Phthisis. 2.00 
Mackenzie. Throat Hospital 

Pharmacopoeia. 5th Ed. 1.00 
McBride. Clinical Manual, 

Colored Plates. 3d Ed. - 7.00 
Potter. Stammering, etc. 1.00 
Sheild. Nasal Obstruction. 1.50 



URINE & URINARY ORGANS. 
Acton. Repro. Organs. 1.75 

Holland. The Urine, Milk and 

Common Poisons. 6th Ed. 1.00 
Kleen. Diabetes. - - 2.50 
Memminger. Diagnosis by 

the Urine. 2d Ed. Illus. 1.00 
Morris. Renal Surgery. 2.00 

Moullin. The Prostate. - 1.75 

i — The Bladder. - 1.50 

Scott. Clinical and Micros. 

Examination of Urine. - 5.00 
Tyson. Exam, of Urine. 1.50 
Van Niiys. Urine Analysis. 1.00 

VENEREAL DISEASES. 

Gowers. Syphilis and the 

Nervous System. - - 1.00 
Sturgis. Manual of. 7th Ed. 1.25 

VISITING LISTS. 

Lindsay and Blakiston's 
Regular Edition. £1.00 to 2.25 

Perpetual Ed. $1.25 to 1.50 

Monthly Ed. .75 to 1.00 



REVISED EDITION. 



TYSON'S PRACTICE 

A TEXT-BOOK FOR PRACTITIONERS AND STUDENTS 
WITH SPECIAL REFERENCE TO DIAGNOSIS AND TREATMENT 

By JAMES TYSON, M.D. 

Professor of Medicine in the University of Pennsylvania ; Physician to the University and 
Philadelphia Hospitals , etc. 



COLORED PLATES AND 125 OTHER ILLUSTRATIONS 
Octavo* J222 Pages- Cloth, $5-50 ; Leather, $6.50 ; Half Russia, $7*50 



The object of this book is — first, to aid the student and physician to recognize 
disease, and, second, to point out the proper methods of treatment. To this end 
Diagnosis and Treatment receive special attention, while pathology and 
morbid anatomy have such consideration as is demanded by their importance as funda- 
mental conditions of a thorough understanding of disease. Dr. Tyson's qualifications 
for writing such a work are unequaled. It is really the outcome of over thirty 
years' experience in teaching and in private and hospital practice* As a 
teacher he has, while devoting himself chiefly to clinical medicine, occupied several 
important chairs, notably those of General Pathology and Morbid Anatomy, and 
Clinical Medicine in the University of Pennsylvania, an experience that has necessarily 
widened his point of view and added weight to his judgment. This, the Second, 
Edition has been most thoroughly revised, parts have been rewritten, new 
material and illustrations have been added, and in many respects it may be considered 
a new book. 

" It is in the writing and preparation of a work of this character that Dr. Tyson stands pre- 
eminent. Those of the profession — and there are many at this time — who have been fortunate to 
have been his pupils during their medical student days, will remember that he brought to his 
lectures and to his writings an amount of industry and care which many other teachers failed to 
bring ; and those who know him best as an author and teacher have expected that his book on the 
Practice of Medicine, when it appeared, would be a credit to himself, and would increase his 
reputation as a medical author. This belief has proved correct. ' ' — Therapeutic Gazette, Detroit, Mich. 

" After a third of a century spent in the assiduous study, practice, and teaching of medicine, 
and the publication of successful books on various topics, theoretical and practical, the writing of a 
text-book is not only a proper ambition, but is really expected by students and the profession. So 
Professor Tyson best shows his modesty by making no apology for the present work." — American 
Journal of Medical Sciences, Philadelphia. 

4 



All prices are net. No discount can be allowed retail purchasers. 



P. BLAKISTON'S SON & CO.'S 

Medical and Scientific Publications, 



Acton. The Functions and Disorders of the Reproductive Organs 

in Childhood, Youth, Adult Age, and Advanced Life, considered in their Physiological, 
Social, and Moral Relations. By Wm. Acton, m.d., m.r.c.s. 8th Edition. Cloth, $1.7$ 

Allen. Commercial Organic Analysis. 

New Revised Editions. A Treatise on the Properties, Proximate Analytical Exami- 
nation and Modes of Assaying the Various Organic Chemicals and Products employed 
in the Arts, Manufactures, Medicine, etc., with Concise Methods for the Detection 
and Determination of Impurities, Adulterations, and Products of Decomposition, etc. 
Revised and Enlarged. By Alfred H. Allen, f.cs., Public Analyst for the West 
Riding of Yorkshire ; Past President Society of Public Analysts of Great Britain. 

Vol. I. Preliminary Examination of Organic Bodies. Alcohols, Neutral Alcoholic 
Derivatives, Ethers, Starch and its Isomers, Sugars, Acid Derivatives of Alcohols 
and Vegetable Acids, etc. Third Edition, with numerous additions by the 
author, and revisions and additions by Dr. Henry Leffmann, Professor of 
Chemistry and Metallurgy in the Pennsylvania College of Dental Surgery, and 
in the Wagner Free Institute of Science, Philadelphia, etc. With many useful 
tables. Cloth, $4.50 

Vol. II — Part I. Fixed Oils, Fats, Waxes, Glycerin, Soaps, Nitroglycerin, 
Dynamite and Smokeless Powders, Wool-Fats, Degras, etc. Third Edition, 
with many useful tables. Revised by Dr. Henry Leffmann, with numerous 
additions by the author. Cloth, $3.50 

Vol. II — Part II. Hydrocarbons, Mineral Oils, Lubricants, Asphalt, Benzene and 
Naphthalene, Phenols, Creosote, etc. Third Edition, Revised by Dr. Henry 
Leffmann, with additions by the author. Cloth, $3.50 

Vol. II — Part III. Terpenes, Essential Oils, Resins, Camphors, Aromatic Acids, 
etc. Third Edition. In Preparation. 

Vol. Ill — Part I. Tannins, Dyes, Coloring Matters, and Writing Inks. Third 
Edition, Revised, Rewritten, and Enlarged by I. Merritt Matthews, Professor 
of Chemistry and Dyeing at the Philadelphia Textile School ; Member American 
Chemical Society. Cloth, $4.50 

Vol. Ill — Part II. The Amines and Ammonium Bases, Hydrazines and Deriva- 
tives. Bases from Tar. The Antipyretics, etc. Vegetable Alkaloids, Tea, 
Coffee, Cocoa, Kola, Cocaine, Opium, etc. Second Edition. 8vo. Cloth, $4. 50 

Vol. Ill — Part III. Vegetable Alkaloids concluded, Non-Basic Vegetable Bitter 
Principles. Animal Bases, Animal Acids, Cyanogen and its Derivatives, etc. 
Second Edition. Cloth, $4. 50 

Vol. IV. Proteids and Albuminous Principles. Proteoi'ds or Albuminoids. 
Second Edition, with elaborate appendices and a large number of useful tables. 

Cloth, $4.50 

Bailey and Cady. Chemical Analysis. 

Laboratory Guide to the Study of Qualitative Analysis. By E. H. S. Bailey, Ph.D., 
Professor of Chemistry, and Hamilton Cady, a.b., Assistant Professor of Chemistry 
in the University of Kansas. Fourth Edition. Cloth, $1.25 



P. BLAKISTON'S SON &* CO.' S 



Ballou. Veterinary Anatomy and Physiology. 
By Wm. R. Ballou, m.d., late Professor of Equine Anatomy, New York College or 
Veterinary Surgeons. With 29 Graphic Illustrations. i2mo. No. 12 fQuiz-Com- 
pend? Series. Cloth, .80 ; Interleaved for the Addition of Notes, $i.oa 

Barrett. Dental Surgery 

for General Practitioners and Students of Medicine and Dentistry. Extraction of 
Teeth, etc. By A. W. Barrett, m.d. Third Ed. 86 Illus. i2mo. Cloth, $1.00 

Bartley. Medical and Pharmaceutical Chemistry. 
A Text-Book for Medical and Pharmaceutical Students. By E. H. Bartley, m.d., 
Professor of Chemistry and Toxicology at the Long Island College Hospital ; Dean 
and Professor of Chemistry, Brooklyn College of Pharmacy ; Chief Chemist, Board 
of Health of Brooklyn, N. Y. Fifth Edition, Revised and Improved. With Illus- 
trations, Glossary, and Complete Index. i2mo. Cloth, $3.00; Leather, $3.50 

" The subject-matter is excellent. The descriptions are detailed and very complete. All of 
these properties make the book an excellent one for a book of reference. Indeed, if the book be 
considered in the light of this purpose, it is hard to find anything in it for adverse criticism." — 
Boston Medical and Surgical Journal. 

Clinical Chemistry. 

The Chemical Examination of the Saliva, Gastric Juice, Feces, Milk, Urine, etc., 
with Notes on Urinary Diagnosis, Volumetric Analysis, and Weights and Meas- 
ures. Illustrated. i2mo. Cloth, $1.00 

Beale. On Slight Ailments. 

Their Nature and Treatment. By Lionel S. Beale, m.d., f.r.s., Professor of 
Practice, King's Medical College, London. Second Edition. 8vo. Cloth, $1.25. 

Beasley's Book of Prescriptions. 

Containing over 3100 Prescriptions, collected from the Practice of the most Eminent 
Physicians and Surgeons — English, French, and American ; a Compendious History 
of the Materia Medica, Lists of the Doses of all Officinal and Established Prepa- 
rations, and an Index of Diseases and their Remedies. By Henry Beasley. 
Seventh Edition. Cloth, $2.oo> 

Druggists' General Receipt Book. 

Comprising a copious Veterinary Formulary ; Recipes in Patent and Proprietary 
Medicines, Druggists' Nostrums, etc. ; Perfumery and Cosmetics ; Beverages, 
Dietetic Articles, and Condiments ; Trade Chemicals, Scientific Processes, and 
an Appendix of Useful Tables. Tenth Edition. Cloth, $2.00 

Pharmaceutical Formulary 

and Synopsis of the British, French, German, and United States Pharmacopoeias. 
Comprising Standard and Approved Formulas for the Preparations and Com- 
pounds Employed in Medical Practice. Twelfth Edition. Cloth, $2.00 

Berry. The Thyroid Gland. 

The Diseases of the Thyroid Gland and Their Surgical Treatment. By James 
Berry, m.b., b.s., f.r.c.s., Surgeon to the Royal Free Hospital. 121 Illustrations, 
from Original Photographs of Cases. Cloth, $4.00 

Biddle's Materia Medica and Therapeutics. Thirteenth Edition. 
Including Dose List, Dietary for the Sick, Table of Parasites, and Memoranda of 
New Remedies. By the late John B. Biddle, m.d. Thirteenth Edition, Revised 
by Clement Biddle, m.d., Assistant Surgeon U. S. Navy. With 64 Illustrations 
and a Clinical Index. Octavo. 



MEDICAL AND SCIENTIFIC PUBLICATIONS. 



Bigelow. Plain Talks on Medical Electricity and Batteries. 
With a Therapeutic Index and a Glossary. By Horatio R. Bigelow, m.d. With 
43 Illustrations and a Glossary. Second Edition. Cloth, $1.00 

Birch. Practical Physiology. 

An Elementary Class-Book. Including Histology, Chemical and Experimental 
Physiology. By De Burgh Birch, m.d., cm., f.r.s.e., Professor of Physiology in 
the Yorkshire College of the Victoria University, etc. 62 Illus. i2mo. Cloth-, $1.75 

Bishop. Uterine Fibromyomata. 

Their Pathology, Diagnosis, and Treatment. By E. Stanmore Bishop, f.r.c.s. 
(Eng.), President Manchester Clinical Society ; Fellow British Gynecological Society. 
Full-page Plates and other Illustrations. Octavo. Cloth, $3.50 

Black. Micro-Organisms. 

The Formation of Poisons. A Biological Study of the Germ Theory of Disease. 
By G. V. Black, m.d., d.d.s. Cloth, .75 

Blackburn. Autopsies. Illustrated. 
A Manual of Autopsies, Designed for the Use of Hospitals for the Insane and other 
Public Institutions. By I. W. Blackburn, m.d., Pathologist to the Government 
Hospital for the Insane. Illustrated. Cloth, $1.25 

Bloxam. Chemistry (Inorganic and Organic). 
With Experiments. By Charles L. Bloxam. Edited by J. M. Thompson, Pro- 
fessor of Chemistry in King's College, London, and A. G. Bloxam, Head of the 
Chemistry Department, Goldsmith's Institute, London. Ninth Edition, Revised and 
Enlarged. 281 Engravings. 8vo. Preparing. 

Bracken. Outlines of Materia Medica and Pharmacology. 

By H. M. Bracken, Professor of Materia Medica and Therapeutics and of Clinical 
Medicine, University of Minnesota. 8vo. Cloth, $2.75 

Broomell. Anatomy and Histology of the Mouth and Teeth. 

By Dr. I. N. Broomell, Professor of Dental Anatomy, Dental Histology, and Pros- 
thetic Technics in the Pennsylvania College of Dental Surgery. Second Edition, 
Enlarged and Revised. 337 handsome Illustrations, the majority of which are 
original. Large Octavo. Just Ready. Cloth, $4.50 

Brown. Medical Diagnosis. Fourth Edition. 
A Manual of Clinical Methods. By J. J. Graham Brown, m.d., f.r.c.p., Lecturer 
on Principles and Practice of Medicine in the School of Medicine of the Royal 
Colleges, Edinburgh. Fourth Edition. 112 Illustrations. i2mo. Cloth, $2.25 

Brubaker. Compend of Physiology. Tenth Edition. 

A Compend of Physiology, specially adapted for the use of Students and Physicians. 
By A. P. Brubaker, m.d., Adjunct Professor of Physiology at Jefferson Medical 
College ; Professor of Physiology, Pennsylvania College of Dental Surgery, Philadel- 
phia. Tenth Edition, Revised, Enlarged, and Illustrated. No. 4 ? Quiz- Compend ? 
Series. i2mo. Cloth, .80; Interleaved, £1.00 

Bulkley. The Skin in Health and Disease. 

By L. Duncan Bulkley, m.d. Illustrated. Cloth. .40 

Bunge. Physiologic and Pathologic Chemistry. 

By Dr. C. Bunge, Professor at Basel. Authorized Translation from the Fourth 
German Edition. Edited by E. A. Starling, m.d., f.r.s., Professor of Physiology 
in University College, London. Octavo. Cloth, $3.00 



P. BLAKISTON'S SON &* CO.' S 



Burnet. Foods and Dietaries. 

A Manual of Clinical Dietetics. By R. W. Burnet, m.d., m.r.c.p., Physician to 
the Great Northern Central Hospital. With Appendix on Predigested Foods and 
Invalid Cookery. Full Directions as to Hours of Taking Nourishment, Quantity, 
etc. Third Edition. Cloth, $1.50 

Burnett. Hearing and How to Keep It. 

By Chas. H. Burnett, m.d., Professor of Diseases of the Ear at the Philadelphia 
Polyclinic. Illustrated. Cloth, .40 

Butlin. The Operative Surgery of Malignant Disease. 

By Henry T. Butlin, f.r.c.s., Assistant Surgeon to, and Demonstrator of Surgery 
at, St. Bartholomew's Hospital, London, etc., assisted by James Berry, f.r.c.s., 
Wm. Bruce-Clarke, m.b., f.r.c.s., A. H. G. Doran, f.r.c.s., Percy Furnivall, 
f.r.c.s., W. H. H. Jessop, m.b., f.r.c.s., and H. J. Waring, b.Sc, f.r.c.s. 
Second Edition, Revised and Rewritten. Illustrated. Octavo. Cloth, $4.50 

Buxton. On Anesthetics. 

A Manual. By Dudley Wilmot Buxton, m.r.c.s., m.r.c.p., Assistant to Professor 
of Medicine and Administrator of Anesthetics, University College Hospital, London. 
Third Edition, Illustrated. i2mo. Cloth, $1.50 

Byford. Manual of Gynecology. 363 Illustrations. 

By Henry T. Byford, m.d., Professor of Gynecology and Clinical Gynecology in 
the College of Physicians and Surgeons of Chicago, and in Post-Graduate Medical 
School, etc. Third Edition, Revised and Enlarged. 363 Illustrations, many of which 
are from original drawings and several of which are Colored. 1 21110. Just Ready. 

Cloth, $3.00 

Caldwell. Chemical Analysis. 

Elements of Qualitative and Quantitative Chemical Analysis. By G. C. Caldwell, 
b.s., Ph.D., Professor of Agricultural and Analytical Chemistry in Cornell Univer- 
sity, Ithaca, New York, etc. Third Edition. Octavo. Cloth, $1.00 

Cameron. Oils and Varnishes. 

By James Cameron, f.i. c. Illustrations, Formulae, Tables, etc. i2mo. Cloth, $2. 25 

Soap and Candles. 

A Handbook for Manufacturers, Chemists, etc. 54 Illustrations. i2mo. Cloth, $2.00 
Campbell. Dissection Outline and Index. 

A Systematic Outline for Students for the Dissection of the Human Body and an 
Arranged Index adapted for Use with Morris' Anatomy. By William A. Campbell, 
b.s., m.d., formerly Demonstrator of Anatomy in the Medical Department of the 
University of Michigan, Ann Arbor. Second Edition, Revised. Cloth, .50 

Canfield. Hygiene of the Sick-Room. 

Being a Brief Consideration of Asepsis, Antisepsis, Disinfection, Bacteriology, Immu- 
nity, Heating and Ventilation, and kindred subjects, for the Use of Nurses and other 
Intelligent Women. By William Buckingham Canfield, a.m., m.d., late Lecturer 
on Clinical Medicine, University of Maryland. i2mo. Cloth, $1.25 

Carpenter. The Microscope and Its Revelations. 

By W. B. Carpenter, m.d., f.r.s. Eighth Edition, by Rev. Dr. Dallinger, 
f.r.s. Rewritten, Revised, and Enlarged. 817 Illustrations and 23 Plates. Octavo. 
1 1 36 pages. Just Ready. Cloth, $8.00; Half Morocco, $9.00 

Chase. General Paresis. 

By Robert H. Chase, m.d., Physician-in-chief Friends' Asylum for the Insane, Frank- 
ford, Philadelphia ; late Resident Physician State Hospital for Insane, Norristown, 
Pennsylvania, etc. Illustrated. Just Ready. Cloth, $1.75 



MEDICAL AND SCIENTIFIC PUBLICATIONS. 9 

Cazeaux and Tarnier's Midwifery. With Appendix, by Munde. 
The Theory and Practice of Obstetrics, including the Diseases of Pregnancy and 
Parturition, Obstetrical Operations, etc. By P. Cazeaux. Remodeled, rearranged, 
and revised by S. Tarnier, m.d. Eighth American from the Eighth French and 
First Italian Edition. Edited by Robert J. Hess, m.d. With an Appendix by Paul 
F. Munde, m.d. Illustrated by Lithographs, Full -page Plates, and numerous En- 
gravings. 8vo. Cloth, $4.50; Full Leather, $5.50 

Clowes and Coleman. Quantitative Analysis. 

Adapted for the Use of the Laboratories of Schools and Colleges. By Frank Clowes, 
Sc.d., Emeritus Professor of Chemistry, University College, Nottingham, and I. 
Bernard Coleman, Assoc. R. C. Sci., Dublin, Professor of Chemistry, Southwest 
London Polytechnic. Fifth Edition. 122 Illustrations. Cloth, $3.50 

Coblentz. Manual of Pharmacy. 
A Text-Book for Students. By Virgil Coblentz, a.m., ph.d., f.c.s., Professor of 
Chemistry and Physics ; Director of Pharmaceutical Laboratory, College of Phar- 
macy of the City of New York. Second Edition, Revised and Enlarged. 437 Illus- 
trations. Octavo. 572 pages. Cloth, $3.50; Sheep, $4.50 

The Newer Remedies. 

Including their Synonyms, Sources, Methods of Preparation, Tests, Solubilities, 
and Doses as far as known. Together with Sections on Organo-Therapeutic 
Agents and Indifferent Compounds of Iron. Third Edition, very much enlarged. 
Octavo. Cloth, $1.00 

Volumetric Analysis. 

A Practical Handbook for Students of Chemistry. Including Indicators, Test- 
Papers, Alkalimetry, Acidimetry, Analysis by Oxidation and Reduction, Iodom- 
etry, Assay Processes for Drugs with the Titrimetric Estimation of Alkaloids, 
Estimation of Phenol, Sugar, Tables of Atomic and Molecular Weights. 
Illustrated. 8vo. Cloth, $1.25 

Cohen. System of Physiologic Therapeutics. Illustrated. 

A Practical Exposition of the Methods Other than Drug-giving, Useful in the Treat- 
ment of the Sick and in the Prevention of Disease. Edited by Solomon Solis 
Cohen, a.m., m.d., Professor of Medicine and Therapeutics in the Philadelphia 
Polyclinic ; Lecturer on Clinical Medicine at Jefferson Medical College ; Physician 
to the Philadelphia Hospital and to the Rush Hospital for Consumption ; formerly 
Lecturer on Therapeutics, Dartmouth Medical College. To be issued in Eleven 
Compact Octavo Volumes. Complete Set, Cloth, $27.50; Half Morocco, $38.50 

Electrotherapy. 220 Illustrations. Two Volumes. Ready. 
By George W. Jacoby, m.d., New York, Consulting Neurologist to the German 
Hospital, to the Infirmary for Women and Children, to the Craig Colony for 
Epileptics, etc. Special articles by Edward Jackson, a.m., m.d., Denver, 
Col. ; Emeritus Professor of Diseases of the Eye in the Philadelphia Polyclinic ; 
Member American Ophthalmological Society ; Fellow and ex-President American 
Academy of Medicine, etc. — By William Scheppegrell, m.d., New Orleans, 
ex-Vice-President American Laryngological, Rhinological, and Otological 
Society. — By J. Chalmers Da Costa, m.d., Clinical Professor of Surgery in 
Jefferson Medical College; Surgeon to the Philadelphia and to St. Joseph's 
Hospitals, etc. — By Franklin H. Martin, m.d., Professor of Gynecology, Post- 
Graduate Medical School of Chicago ; Gynecologist Chicago Charity Hospital ; 
Chairman Section of Obstetrics and Diseases of Women of the American Medi- 
cal Association (1895), etc - — By A. H. Ohmann-Dumesnil, m.d., Editor St. 
Louis Medical and Surgical Journal ; Member International Dermatological 
Congress ; formerly Professor of Dermatology, St. Louis Medical College, etc. 



10 p. BLAKISTON'S SON &■> CO.' S 

Cohen. Physiologic Therapeutics. — Continued. 

Climatology and Health Resorts, Including Mineral Springs. 
Two Volumes, with Colored Maps. Ready. 

By F. Parkes Weber, m.a., m.d., f.r.c.p. (Lond.), Physician to the German 
Hospital, Dalston ; Assistant Physician North London Hospital for Consump- 
tion ; Author of "The Mineral Waters and Health Resorts of Europe ;" and 
Guy Hinsdale, a.m., m.d., Secretary of the American Climatological Associa- 
tion ; President of the Pennsylvania Society for the Prevention of Tuberculosis, 
etc. Including an article on Hawaii by Titus Munson Coan, m.d., of New 
York. With Colored Maps, prepared by Dr. W. F. R. Phillips, of the U. S. 
Weather Bureau, Washington, D. C. 

Prophylaxis — Personal Hygiene — Care of the Sick. Illustrated. 
By Dr. Joseph McFarland, Professor of Pathology, Medico-Chirurgical College, 
Philadelphia; Dr. Henry Leffmann, Professor of Chemistry in the Woman's 
Medical College, Philadelphia; Albert Abrams, a.m., m.d. (University of 
Heidelberg), formerly Professor of Pathology, Cooper Medical College, San 
Francisco ; and Dr. W. Wayne Babcock, Lecturer on Pathology and Bac- 
teriology, Medico-Chirurgical College, Philadelphia. 

Dietotherapy : Food in Health and Disease. Ready, 

By Nathan S. Davis, Jr., a.m., m.d., Professor of Principles and Practice of 
Medicine in Northwestern University Medical School ; Physician to Mercy Hos- 
pital, Chicago ; Member American Academy of Medicine, American Climato- 
logical Society, etc. With Tables of Dietaries, Relative Value of Foods, etc. 

Mechanotherapy and Physical Education. Illustrated. 

By John Kearsley Mitchell, m.d., Assistant Physician to the Orthopedic 
Hospital and Infirmary for Nervous Diseases ; Assistant Neurologist Presbyterian 
Hospital, Philadelphia, etc. ; formerly Lecturer on Symptomology at the Univer- 
sity of Pennsylvania; and Luther Gulick, m.d., of Brooklyn, N. Y., formerly 
of Springfield, Mass., Mem. American Association for Advancement of Physical 
Education, Amer. Medical Association, etc. With a Chapter on Orthopedic 
Appliances by James K. Young, m.d., Professor of Orthopedic Surgery, Phila- 
delphia Polyclinic ; Instructor in Orthopedic Surgery, University of Pennsylvania ; 
and an Article on Ocular Orthopedics by Walter L. Pyle, m.d. 

Rest — Mental Therapeutics — Suggestion. 

By Francis X. Dercum, m.d., Clinical Professor of Nervous Diseases in Jeffer- 
son Medical College ; Neurologist to the Philadelphia Hospital ; Consulting 
Physician to the State Asylum for the Chronic Insane at Wernersville, Penna. ; 
Consulting Neurologist to St. Agnes' Hospital ; Neurologist to the Jewish Hos- 
pital of Philadelphia. 

Hydrotherapy — Thermotherapy — Heliotherapy — Crounother- 
apy — Phototherapy — Balneology. Ready. 
By Dr. Wilhelm Winternitz, Professor of Clinical Medicine in the University 
of Vienna ; Director of the General Polyclinic in Vienna, etc. ; assisted by 
Dr. Alois Strasser, Instructor in Clinical Medicine, University of Vienna ; 
and Dr. B. Buxbaum, Chief Physician of the Hydrotherapeutic Institute of 
Vienna ; and Dr. E. Heinrich Kisch, Professor in the University of Prague ; 
Physician at Marienbad Spa. With Special Chapters by Dr. A. C. Peale, of the 
National Museum, Washington, D. C, Dr. J. H. Kellogg, Battle Creek, 
Mich., and Harvey Cushing, m.d., Johns Hopkins Hospital, Baltimore, and 
an Appendix by Dr. Cohen. 

Pneumatotherapy and Inhalation Methods. Illustrated. 

By Dr. Paul Tissier, Chief of Clinic of the Faculty of Medicine of Paris. 



MEDICAL AND SCIENTIFIC PUBLICATIONS. 11 

Cohen. Physiologic Therapeutics. — Continued. 

Serotherapy — Organotherapy — Blood-Letting, etc. — Principles of 
Therapeutics — Digest — I ndex. 

By Joseph McFarland, m.d., Professor of Pathology in the Medico-Chirurgical 
College, Philadelphia ; Pathologist to the Medico Chirurgical Hospital, etc. — 
O. T. Osborne, m.d., Professor of Materia Medica and Therapeutics, Medical 
Department, Yale University, New Haven. — Frederick A. Packard, m.d., 
Visiting Physician to the Pennsylvania and to the Children's Hospitals. — The 
Editor, and Augustus A. Eshner, m.d., Professor of Clinical Medicine in the 
Philadelphia Polyclinic ; Physician to the Philadelphia Hospital, etc. 

*** Complete descriptive circular upon application. 

" There is surely room for just such a set of books. We have been too prone to think that we 
were teaching therapeutics sufficiently when we taught our students the old materia medica and the 
use of mere drugs, forgetful and careless of the importance of the therapeutic value of the methods 
of which this series of books will speak." — Johns Hopkins Hospital Bulletin. 

Cohen. The Throat and Voice. 

By J. Solis Cohen, m.d. Illustrated. i2mo. Cloth, .40 

Congdon. Laboratory Instructions in General Chemistry. 

By Ernest A. Congdon, Professor of Chemistry in the Drexel Institute, Philadelphia ; 
Member American Chemical Society ; Fellow of the London Chemical Society, etc. 
With an Appendix, useful Tables, and 56 Illustrations. Interleaved, Cloth, $1.00 

Conn. Agricultural Bacteriology. 

Including a Study of Bacteria as Relating to Agriculture, with Special Reference to 
the Bacteria in Soil, in the Dairy, in Food Products, in Domestic Animals, and in 
Sewage. By H. W. Conn, Ph.D., Professor of Biology, Wesleyan University, 
Middletown, Conn. ; Author of " Evolution of To-day," " The Story of Germ Life," 
etc. With Illustrations. Cloth, $2.50 

The Relation of Bacteria to Milk Products. 

Designed for Students of Dairying, Boards of Health, and Bacteriologists. Illus- 
trated. i2mo. In Press. 

Coplin. Manual of Pathology. Third Edition. 330 Illustrations. 

Including Bacteriology, the Technic of Post-mortems, and Methods of Pathologic 
Research. By W. M. Late Coplin, m.d., Professor of Pathology and Bacteriology, 
Jefferson Medical College ; Pathologist to Jefferson Medical College Hospital and to 
the Philadelphia Hospital ; Bacteriologist to the Pennsylvania State Board of Health. 
Third Edition, Rewritten and Enlarged. 330 Illustrations, many of which are origi- 
nal, and 7 Colored Plates. 8vo. Cloth, $3.50 

Practical Hygiene. 

With Special Articles on Plumbing, Ventilation, etc. 138 Illustrations. 8vo. 
Second Edition. In Preparation. 

Crocker. Diseases of the Skin. Third Edition. 

Their Description, Pathology, Diagnosis, and Treatment, with Special Reference to 
the Skin Eruptions of Children. By H. Radcliffe Crocker, m.d., Physician to 
the Department of Skin Diseases, University College Hospital, London. Third Edi- 
tion, Thoroughly Revised, with new Illustrations. Nearly Ready. Cloth, $5.00 

Cuff. Lectures on Medicine to Nurses. 
By Herbert Edmund Cuff, m.d., late Assistant Medical Officer, Stockwell Fever 
Hospital, England. Third Edition, Revised. With 25 Illustrations. Cloth, $1.25 



12 P. BLAKISTON'S SON &* CO.'S 



Cushing. Compend of Histology. 

Specially adapted for the use of Medical Students and Physicians. By H. H. Cushing, 
m.d., Director of Histological and Embryological Laboratories, Woman's Medical 
College of Pennsylvania ; Demonstrator of Histology and Embryology, Jefferson 
Medical College, Philadelphia. Illustrated. Ab. iy ? Quiz -Compend? Series, 
i2mo. In Press. Cloth, .80; Interleaved for Notes, $1.00 

Davis. Dietotherapy. Food in Health and Disease. 
See Cohen, Physiologic Therapeutics, page 10. 

Davis. Essentials of Materia Medica and Prescription Writing. 
By J. Aubrey Davis, m.d. i2mo. Cloth, $1.50 

Davis. The Principles and Practice of Bandaging. 

By Gwilym G. Davis, m.d., m.r.c.s., Universities of Pennsylvania and Gottingen, 
Assistant Demonstrator of Surgery, University of Pennsylvania ; Surgeon to the Out- 
Patient Departments of the Episcopal and Children's Hospitals ; Assistant Surgeon 
to the Orthopaedic Hospital. Second Edition, Revised and Rewritten. 163 Illustra- 
tions, Redrawn specially for this edition. Just Ready. Cloth, #1.50 

Domville. Manual for Nurses 

and Others Engaged in Attending to the Sick. By Ed. J. Domville, m.d. Ninth 
Edition, Revised. With Recipes for Sick-room Cookery, etc. i2mo. In Press. 

Donders. Refraction. Portrait of Author. 

An Essay on the Nature and the Consequences of Anomalies of Refraction. By F. 
C. Donders, m.d. Authorized Translation. Revised and Edited by Charles A. 
Oliver, a.m., m.d. (Univ. Pa.), one of the Attending Surgeons to the Wills Eye 
Hospital. With a Portrait of the Author. Octavo. Half Morocco, Gilt, $1.25 

Da Costa. Clinical Hematology. Colored Plates. 

A Practical Guide to the Examination of the Blood by Clinical Methods, with Refer- 
ence to the Diagnosis of Disease. By John C. Da Costa, Jr., m.d., Assistant 
Demonstrator of Clinical Medicine in the Jefferson Medical College, Philadelphia ; 
Assistant in the Medical Clinic, Jefferson Medical College Hospital ; Haematologist 
to the German Hospital. With six Colored Plates and 48 other Illustrations. Octavo. 
Just Ready. Cloth, #5.00; Sheep, $6.00 

Deaver. Surgical Anatomy. 450 Full-page Plates. 

A Treatise on Human Anatomy in its Application to the Practice of Medicine and 
Surgery. By John B. Deaver, m.d., Surgeon-in-Chief to the German Hospital; 
Surgeon to the Children's Hospital and to the Philadelphia Hospital; Consulting 
Surgeon to St. Agnes', St. Timothy's, and Germantown Hospitals ; formerly Assistant 
Professor of Applied Anatomy, University of Pennsylvania, etc. With over 450 
very handsome Full-page Illustrations engraved from original drawings made by 
special artists from dissections prepared for the purpose in the dissecting-rooms of the 
University of Pennsylvania. Three large volumes. Royal square octavo. Sold by 
Subscription. Orders taken for complete sets only. Description upon Application 
Cloth, $21.00 ; Half Morocco or Sheep, $24.00 ; Half Russia, $27.00 

Synopsis of Contents. 
Volume I. — Upper Extremity — Back of Neck, Shoulder, and Trunk — Cranium 

— Scalp — Face. 
Volume II. — Neck — Mouth, Pharynx, Larynx, Nose — Orbit — Eyeball — Organ 

of Hearing — Brain — Female Perineum — Male Perineum. 
Volume III. — Abdominal Wall — Abdominal Cavity — Pelvic Cavity — Chest — 

Lower Extremity. 

See next page Jor Reviews. 



MEDICAL AND SCIENTIFIC PUBLICATIONS. 13 

Deaver'S Surgical Anatomy 



The illustrations, which at the first glance appear as the prominent feature of 
the book — but which in reality do not overshadow the text — consist of a series of 
pictures absolutely unique and fresh. They will bear comparison from an artistic point 
of view with any other work, while from a practical point of view there is no other 
volume or series of volumes to which they can be compared. When originally an- 
nounced, the book was to contain two hundred illustrations. As the work of prepara- 
tion progressed, this number gradually increased to more than four hundred and fifty 
fuil-page plates, many of which contain more than one figure. With the exception of 
a few minor pictures made from preparations in the possession of the author, they have 
all been drawn by special artists from dissections made for the purpose in the dissecting- 
rooms of the University of Pennsylvania. Their accuracy cannot be questioned, as 
each drawing has been submitted to the most careful scrutiny. 

From The Medical Record, New York. 

44 The reader is not only taken fay easy and natural stages from the more superficial to the 
deeper regions, but the various important regional landmarks are also indicated by schematic 
tracing upon the limbs* Thus the courses of arteries, veins, and nerves are indicated in a way that 
makes the lesson strikingly impressive and easily learned. No expense, evidently, has been 
spared in the preparation of the work, judging from the number of full-page plates it contains, not 
counting the smaller drawings. Most of these have been ' drawn bv special artists from dissections 
made for the purpose in the dissecting-rooms of the University of Pennsylvania.' In summing up 
the general excellences of this remarkable work, we can accord our unqualified praise for the 
accurate, exhaustive, and systematic manner in which the author has carried out his plan, and we 
can commend it as a model of its kind, which must be possessed to be appreciated/' 

From The Philadelphia Medical Journal. 

" Many members of the profession to whom Dr. Deaver is well known either personally or by 
reputation as a surgeon, writer, teacher, and practical anatomist, have awaited the appearance of 
his Surgical Anatomy with the expectation of finding in it a guide in this difficult branch of medi- 
cine of much more than ordinary practical value, and their expectations will not be disappointed /' 

From The Journal of the American Medical Association. 

" In order to show its thoroughness, it is only necessary to mention that no less than twelve 
full-page plates are reproduced in order to accurately portray the surgical anatomy of the hand, 
and it is doubtful whether any better description exists in any work in the English language." 

From The Southern California Practitioner. 

" Aside from the merit of this great work, it will be a delight to the lover of books. Its gen- 
'eral make-up shows the highest development of the book-making art. The bibliophile, when 
holding one of these volumes in his hands, would be as careful with it as though he were handling 
an infant, and to drop it would cause him the keenest pain. The illustrations, the print, and the 
paper and binding are each and all delightful in themselves, and yet the text is concise and clear, 
and taken with the illustrations make a remarkably good substitute for the dissecting-room. To 
have these three volumes on his library shelves will be a source of pride and joy and profit to 
every practitioner. Dr. Deaver has in these volumes conferred a boon upon the medical profession 
which has, at least, never been surpassed by any one." 

From The New Orleans Medical and Surgical Journal. 

" While the needs of the undergraduate have been fully kept in view, it has been the aim of 
the author to provide a work which would be sufficient for reference for use in actual practice. We 
believe the book fulfils both requirements. The arrangement is systematic and the discussion of 
surgical relations thorough/' 

j$gi~ Large Descriptive Circular will be sent upon application 



14 P. BLAKISTON'S SON 6- CO.'S 

Deaver. Appendicitis. Third Edition. 

Its History, Anatomy, Etiology, Pathology, Symptoms, Diagnosis, Prognosis, Treat- 
ment, Complications, and Sequelae. With 22 Plates, 10 of which are Colored. 
Third Edition, Revised and Rewritten. Preparing. 

Dercum. Rest — Mental Therapeutics — Suggestion. 
See Cohen, Physiologic Therapeutics, page 10. 

Duhrssen. A Manual of Gynecological Practice. 

By Dr. A. Duhrssen, Privat-Docent in Midwifery and Gynecology in the University 
of Berlin. Translated from the Fourth German Edition and Edited by John W. 
Taylor, f.r.c.s., Surgeon to the Birmingham and Midlands Hospital for Women ; 
Vice-President of the British Gynecological Society; and Frederick Edge, m.d., 
m.r.c.p., f.r.c.s., Surgeon to the Wolverhampton and District Hospital for Women. 
With 105 Illustrations. i2mo. Cloth, $1.50 

Dulles. What to Do First In Accidents and Poisoning. 

By C. W. Dulles, m.d., Surgeon to the Rush Hospital ; formerly Assistant Surgeon 
2d Regiment N. G. Pa., etc. Fifth Edition, Enlarged. With new Illustrations. 
i2mo. Cloth, $1.00 

Edgar. The Practice of Obstetrics. 

By J. Clifton Edgar, m.d., Professor of Obstetrics Medical Department of Cornell 
University, New York City ; Physician to Mothers' and Babies' Hospital, and to the 
Emergency Hospital, etc. W T ith many Illustrations, a large number of which are 
Original. Octavo. In Press. 

Emery. A Handbook of Bacteriological Diagnosis. 

By W. d'Este Emery, m.d., b.Sc. Lond., Lecturer in Pathology and Bacteriology in 
the University of Birmingham. With two colored plates and 32 other illustrations. 
Just Ready. Cloth, $1.50 

Eagge. Practice of Medicine. 

A Text-Book of Medicine by the late C. Hilton Fagge, m.d. Fourth Edition, 
Revised and Edited by P. H. Pye-Smith, m.d., f.r.s., f.r.c.p., Consulting Physi- 
cian to Guy's Hospital, London, etc. Two Vols. 8vo. Vol. I, Just Ready. 

Cloth, $6.00 
Vol. II, Nearly Ready. 

Fick. Diseases of the Eye and Ophthalmoscopy. 

A Handbook for Physicians and Students. By Dr. Eugen Fick, University of 
Zurich. Authorized Translation by A. B. Hale, m.d., Ophthalmic Surgeon United 
Hebrew Charities ; Consulting Ophthalmic Surgeon Charity Hospital, Chicago ; late 
Vol. Assistant Imperial Eye Clinic, University of Kiel. With a Glossary and 158 
Illustrations, many of which are in Colors. 8vo. 

Cloth, $4-5o; Sheep, $5.50; Half Russia, $6.50 

Fillebrown. A Text-Book of Operative Dentistry. 

Written by invitation of the National Association of Dental Faculties. By Thomas 
Fillebrown, m.d., d.m.d., Professor of Operative Dentistry in the Dental School of 
Harvard University ; Member of the American Dental Association, etc. Illustrated. 
8vo. Cloth, $2.25 

Fowler's Dictionary of Practical Medicine. 

By Various Writers. An Encyclopedia of Medicine. Edited by James Kingston 
Fowler, m.a., m.d., f.r.c.p., Senior Assistant Physician to, and Lecturer on Patho- 
logical Anatomy at, the Middlesex Hospital, London. 8vo. 

Cloth, $3.00 ; Half Morocco, #4.00 



MEDICAL AND SCIENTIFIC PUBLICATIONS. lb 

Fullerton. Obstetric Nursing. 

By Anna M. Fullerton, m.d., Demonstrator of Obstetrics in the Woman's Medical 
College ; Obstetrician and Gynecologist to the Woman's Hospital, Philadelphia, etc. 
41 Illustrations. Fifth Edition, Revised and Enlarged. i2mo. Cloth, $1.00 

Surgical Nursing. 

Comprising the Regular Course of Lectures upon Abdominal Surgery, Gyne- 
cology, and General Surgical Conditions delivered at the Training School of 
the Woman's Hospital, Philadelphia. Third Edition, Revised. 69 Illustrations. 
i2mo. Cloth, $1.00 

Gardner. The Brewer, Distiller, and Wine Manufacturer. 

A Handbook for all interested in the Manufacture and Trade of Alcohol and its 
Compounds. Edited by John Gardner, f.c.s. Illustrated. Cloth, $1.50 

Goodall and Washbourn. A Manual of Infectious Diseases. 

By Edward W. Goodall, m.d. (London), Medical Superintendent Eastern (Fever) 
Hospital, Homerton, London, etc. ; and J. W. Washbourn, f.r.c.p., Assistant 
Physician to Guy's Hospital and Physician to the London Fever Hospital. Illustra- 
ted with Charts, Diagrams, and Full-page Plates. Cloth, $3.00 

Gould. The Illustrated Dictionary of Medicine, Biology, and 
Allied Sciences. Fifth Edition. 
Being an Exhaustive Lexicon of Medicine and those Sciences Collateral to * it : 
Biology (Zoology and Botany), Chemistry, Dentistry, Pharmacology, Microscopy, 
etc. By George M. Gould, a.m., m.d., Editor of American Medicine ; President, 
1893-94, American Academy of Medicine, etc. With many Useful Tables and numer- 
ous Fine Illustrations. Large Square Octavo. 1633 pages. Fifth Edition. 

Full Sheep or Half Dark-Green Leather, $10.00 
With Thumb Index, $11.00 ; Half Russia, Thumb Index, $12.00 

"Few persons read dictionaries as Theophile Gautier did — for pleasure; if, however, all 
dictionaries were as readable as the one under consideration, his taste for this kind of literature 
would be less singular. . . . The book is excellently printed, and the illustrations are admir- 
ably executed. The binding is substantial and even handsome, but the business-like ' get-up ' of 
the book makes it well fitted for use as well as for the adornment of a book-shelf." — The British 
Medical Journal, London. 

The Student's Medical Dictionary. Eleventh Ed. Illustrated. 
Enlarged. Including all the Words and Phrases generally used in Medicine, 
with their proper Pronunciations and Definitions, based on Recent Medical 
Literature. With Tables of the Bacilli, Micrococci, Leukomains, Ptomains, 
etc., of the Arteries, Muscles, Nerves, Ganglia, and Plexuses; Mineral Springs 
of the U. S., etc., and a new Table of Eponymic Terms and Tests. Rewritten, 
Enlarged, and Improved. With many Illustrations. Small octavo. 840 pages. 

Half Morocco, $2.50; Thumb Index, $3.00 

" One pleasing feature of the book is that the reader can almost invariably find the definition 
under the word he looks for, without being referred from one place to another, as is too commonly 
the case in medical dictionaries. The tables of the bacilli, micrococci, leukomains, and ptomains 
are excellent, and contain a large amount of information in a limited space. The anatomical tables 
are also concise and clear. . . . We should unhesitatingly recommend this dictionary to our 
readers, feeling sure that it will prove of much value to them." — The American Journal of 
Medical Science. 



16 P. BLAKISTON'S SON &- CO.'S 

Gould. The Pocket Pronouncing Medical Lexicon. Fourth Edition. 
(30,000 Medical Words Pronounced and Denned.) 
A Student's Pronouncing Medical Lexicon. Containing all the Words, their Defini- 
tions and Pronunciations, that the Student generally comes in contact with ; also 
elaborate Tables of the Arteries, Muscles, Nerves, Bacilli, etc., etc.; a Dose List in 
both English and Metric Systems, a new table of Clinical Eponymic Terms, etc., 
arranged in a most convenient form for reference and memorizing. Thin 641110. 
(6x 3^ inches.) 838 pages. The System of Pronunciation used in this book is very 
simple. A A T ew Edition. 

Full Limp Leather, Gilt Edges, $1.00 ; With Thumb Index, $1.25 

" This ' Dictionary ' is admirably suited to the uses of the lecture-room, or for the purposes of 

a medical defining vocabulary — many of the words not yet being found in any other dictionary, 

large or small, while all of the words are those of the living medical literature of the day." — The 

Virginia Medical Monthly. 

*#.* 140,000 copies of Gould's Dictionaries have been sold. 
Sample pages and descriptive circulars of Gould' s Dictiotiaries free upon application. 

Borderland Studies. 

Miscellaneous Addresses and Essays Pertaining to Medicine and the Medical 
Profession, and their Relations to General Science. 350 pages. i2mo. Cloth, $2.00 

Gould and Pyle. Cyclopedia of Practical Medicine and Surgery. 

72 Special Contributors. Illustrated. One Volume. 

A Concise Reference Handbook, Alphabetically Arranged, of Medicine, Surgery, 
Obstetrics, Materia Medica, Therapeutics, and the various specialties, with Particular 
Reference to Diagnosis and Treatment. Compiled under the Editorial Supervision 
of Drs. George M. Gould and W. L. Pyle. With many Illustrations. 
Large Square Octavo. Uniform with Gould's "Illustrated Dictionary." 

Full Sheep or Half Dark-Green Leather, $10.00 ; With Thumb Index, $11.00 

Half Russia, Thumb Index, $12.00 

*£* The great success of Dr. Gould's "Illustrated Dictionary of Medicine" sug- 
gested the preparation of this companion volume, which should be to the physician the 
same trustworthy handbook in the broad field of general information that the Dictionary 
is in the more special one of the explanation of words and the statement of facts. The 
aim^has been to provide in a one-volume book all the material usually contained in the 
large systems and much which they do not contain. Instead of long, discursive papers 
on special subjects there are short, concise, pithy articles alphabetically arranged, giv- 
ing the latest methods of diagnosis, treatment, and operating — a working book in which 
the editors and their collaborators have condensed all that is essential from a vast 
amount of literature and personal experience. 

The seventy-two special contributors have been selected from all parts of the 
country in accordance with their fitness for treating special subjects about which they 
may be considered expert authorities. They are all men of prominence, teachers, 
investigators, and writers of experience, who give to the book a character unequaled by 
any other work of the kind. 

At each reprinting this Cyclopedia is carefully revised and augmented so as to in- 
clude important innovations and in order to keep it up-to-date. 

"The book is a companion volume to Gould's 'Illustrated Dictionary of Medicine,' which 
every physician should possess. With these two books in his library, every busy physician will save 
a vast amount of time in having at hand an instant reference cyclopedia covering every subject in 
surgery and medicine." — Chicago Medical Recorder. 

Pocket Cyclopedia of Medicine and Surgery. 

Based upon Gould and Pyle's Cyclopedia of Practical Medicine and Surgery. 
Uniform with Gould's Pocket Dictionary. 

Full Limp Leather, Gilt Edges, $1.00 ; With Thumb Index, $1.25 

See next page for List of Contributors. 



MEDICAL AND SCIENTIFIC PUBLICATIONS. 



17 



Gould and Pyle's Cyclopedia of Medicine 

LIST OF CONTRIBUTORS 



Samuel W. Abbott, A.M., M.D., Boston. 

James M. Anders, M.D., LL.D., Phila. 

Joseph D. Bryant, M.D., New York. 

James B. Bullitt, M.D., Louisville. 

Charles H. Burnett, A.M., M.D., Phila. 

J. Abbott Cantrell, M.D., Philadelphia. 

Archibald Church, M.D., Chicago. 

L. Pierce Clark, M.D., Sonyea, N. Y. 

Solomon Solis-Cohen, M.D., Philadelphia. 

Nathan S. Davis, Jr., M.D., Chicago. 

Theodore Diller, M.D., Pittsburg. 

Augustus A. Eshner, M.D., Philadelphia. 

J. T. Eskridge, M.D., Denver, Col. 

J. McFadden Gaston, A. B., M.D., Atlanta, 
Ga. 

J. McFadden Gaston, Jr., A.M., M.D., At- 
lanta, Ga. 

Virgil P. Gibney, M.D., New York. 

George M. Gould, A.M., M.D., Phila. 

W. A. Hardaway, A.M., M.D., St. Louis. 

John C. Hemmeter, M.B., M.D., Baltimore. 

Barton Cooke Hirst, M.D., Philadelphia. 

Bayard Holmes, M.D., Chicago. 

Orville Horwitz, B.S., M.D., Philadelphia. 

Daniel E. Hughes, M.D., Philadelphia. 

James Nevins Hyde, A.M., M.D., Chicago. 

E. Fletcher Ingals, A.M., M.D., Chicago. 

Abraham Jacobi, M.D., New York. 

William W. Johnston, M.D., Washington, 
D.C. 

Wyatt Johnston, M.D., Montreal. 

Allen A.Jones, M.D., Buffalo. 

William W. Keen, M.D., LL.D., Phila. 

Howard S. Kinne, M.D., Philadelphia. 

Ernest Laplace, M.D., Philadelphia. 

Benjamin Lee, M.D., Philadelphia. 

Charles L. Leonard, M.D., Philadelphia. 

James Hendrie Lloyd, A.M., M.D., Phila. 

J. W. MacDonald, M.D. (Edin.), F.R.C.S. 
Ed., Minneapolis. 

L. S. McMurtry, M.D., Louisville. 

G. Hudson Makuen, Philadelphia. 



Matthew D. Mann, M.C, Buffalo. 

Henry O. Marcy, A.M., M.D., LL.D., 

Boston. 
Rudolph Matas, M.D., New Orleans. 
Joseph M. Mathews, M.D., Louisville. 
John K. Mitchell, M.D., Philadelphia. 
Harold N. Moyer, M.D., Chicago. 
John H. Musser, M.D., Philadelphia. 
A. G. Nicholls, M.D., Montreal. 

A. H. Ohmann-Dusmesnil, M.D., St. 
Louis. 

William Osier, M.D., Baltimore. 

Samuel O. L. Potter, A.M., M.D., M.R. 

C.P. (London), San Francisco. 
Walter L. Pyle, A.M., M.D., Philadelphia. 

B. Alexander Randall, A.M., M.D., Phila. 
Joseph Ransohoff, M.D., F.R.C.S. (Eng.), 

Cincinnati. 
Jay F. Schamberg, A.M., M.D., Phila. 
Nicholas Senn, M.D., LL.D., Chicago. 
Richard Slee, M.D., Swiftwater, Pa. 
S. E. Solly, M.D., M.R.C.S., Colorado 

Springs, Col. 
Edmond Souchon, M.D., New Orleans. 
Ward F. Sprenkel, M.D., Philadelphia. 
Charles G. Stockton, M.D., Buffalo. 
John Madison Taylor, A.M., M.D., Phila. 
William S. Thayer, M.D., Baltimore. 
James Thorington, A.M., M.D., Phila. 
Martin B. Tinker, M.D., Philadelphia. 
James Tyson, M.D., Philadelphia. 
J. Hilton Waterman, M.D., New York. 
H. A. West, M.D., Galveston, Texas. 
J. William White, M.D., PH.D., Phila. 
Reynold W. Wilcox, M.A., M.D., LL.D., 

New York. 
George Wilkins, M.D., Montreal. 
DeForest Willard, M.D. /Philadelphia. 
Alfred C. Wood, M.D., Philadelphia. 
Horatio C. Wood, M.D., LL.D., Phila." 
Albert Woldert, PH.G., M.D., Phila. 
James K. Young, M.D., Philadelphia. 



" It is difficult to describe the volume before us, and one must imagine all that is clinical 
at the present day as being briefly and yet sufficiently set forth under an alphabetical 
arrangement, with frequent illustrations, with many formulae and diagnostic distinctions, and 
with perfect homogeneity ; then he will have a fair picture of the work. We feel sure, however, 
that many of our readers will make the better acquaintance of the book by becoming its possessors, 
and we commend it to them without hesitation. We have yet to find wherein it is erroneous or 
disappointing, and we regard it as of unlimited value to the average medical man." — The 
New York Medical Journal. 

* '** Sample pages and description upon application. 



18 P. BLAKISTON'S SON &* CO.'S 

Gould and Pyle. Compend of Diseases of the Eye. 

Including Refraction Treatment and Operations, with a Section on Local Therapeutics. 
With Formulae, Glossary, and several Tables. By Drs. George M. Gould and 
W. L. Pyle. Second Edition. 109 Illustrations, several of which are Colored. 
No. 8 ? Quiz- Compend? Series. Cloth, 80.; Interleaved for Notes, $1.00 

Gordinier. The Gross and Minute Anatomy of the Central Nervous 

System. 261 Illustrations. 

By H. C. Gordinier, a.m., m.d., Professor of Physiology and of the Anatomy of 
the Nervous System in the Albany Medical College ; Member American Neurological 
Association. With 48 Full-page Plates and 213 other Illustrations, a number of 
which are printed in Colors and many of which are original. Large 8vo. 

Handsome Cloth, $6.00 ; Sheep, $7.00 ; Half Russia, $8.00 
" This is an excellent book on a fascinating subject, and the author deserves the thanks of the 
English-speaking medical world for his labor in getting it up. There are works enough on general 
anatomy, and dry enough they are, as we all remember only too well ; but the anatomy of the 
nervous system alone is another matter entirely, for it is one of the most interesting of all subjects 
of medical study at the same time that it is one of the most difficult." — The Medical Record, N. Y. 

Gorgas' Dental Medicine. 

A Manual of Dental Materia Medica and Therapeutics. By Ferdinand J. S. Gorgas, 
m.d., d.d.s., Professor of the Principles of Dental Science, Oral Surgery, and Dental 
Mechanism in the Dental Department of the University of Maryland. Seventh 
Edition, Revised and Enlarged, with many Formulas. 8vo. Just Ready. 

Cloth, $4.00 ; Sheep, $5.00 ; Half Russia, $6.00 

Questions and Answers. 

Embracing the Curriculum of the Dental Student. Divided into three parts. 
By Ferdinand J. S. Gorgas, a.m., m.d., d.d.s., Author of " Dental Medicine," 
Editor of "Harris' Principles and Practice of Dentistry " and "Harris' Dictionary 
of Medical Terminology and Dental Surgery," Professor of the Principles of 
Dental Science, Oral Surgery, etc., in the University of Maryland, Dental 
Department, Baltimore, Octavo. Just Ready. Cloth, $6.00 

Gray. A Treatise of Physics. 

By Andrew Gray, ll.d., f.r.s., Professor of Natural Philosophy in the University 
of Glasgow. In Three Volumes. 

Vol. I. Dynamics and Properties of Matter. 350 Illustrations. Octavo. 
688 pages. Cloth, $4- 5° 

Greeff. The Microscopic Examination of the Eye. 

By Professor R. Greeff. Surgeon :o the Ophthalmic Department of the Royal Charite" 
Hospital, Berlin. Translated from the Second German Edition by Hugh Walker, 
m.a., m.d., Assistant Surgeon and Pathologist to the Ophthalmic Department of the 
Glasgow Royal Infirmary. i2mo. Just Ready. Cloth, $1.25 

Greene. The Medical Examination for Life Insurance 

and its Associated Clinical Methods. With Chapters on the Insurance of Sub- 
standard Risks and Accident Insurance. By Charles Lyman Greene, m.d., of St. 
Paul, Clinical Professor of Medicine and Physical Diagnosis in the University of Min- 
nesota. With 99 Illustrations, many of which are original, several being printed 
in Colors. Octavo. Cloth, $4.00 

Griffith's Graphic Clinical Chart. 

Designed by J. P. Crozer Griffith, m.d., Instructor in Clinical Medicine in the 
University of Pennsylvania. Sample copies free. Put up in loose packages of 50, . 50 
Price to Hospitals: 500 copies, $4.00; 1000 copies, $7.50. 



MEDICAL AND SCIENTIFIC PUBLICATIONS. 19 

Groff. Materia Medica for Nurses. 

With Questions for Self-examination. By John E. Groff, Pharmacist to the Rhode 
Island Hospital, Providence. Second Edition, Revised and Improved. i2mo. 
Just Ready. Cloth, $1.25 

Groves and Thorp. Chemical Technology. 

A New and Complete Work. The Application of Chemistry to the Arts and Manu- 
factures. Edited by Charles E. Groves, f.r.s., and Wn. Thorp, b.sc, f.i.c, 
assisted by many experts. With numerous Illustrations. Each volume sold separately. 
Vol. I. Fuel and Its Applications. 607 Illustrations and 4 Plates. Octavo. 

Cloth, $5.00; y z Mor., $6.50 

Vol. II. Lighting. Candles, Oils, Lamps, etc. By W. Y. Dent, L. Field, 

Boverton Redwood, and D. A. Louis. Illustrated. 

Octavo. Cloth, $4.00; y 2 Mor., $5.50 

Vol. III. Gas Lighting. By Charles Hunt, Manager of the Birmingham 

Gasworks. Illustrated. Octavo. 

Cloth, $3.50; y 2 Mor., $4.50 
Vol. IV. Electric Lighting and Photometry. By Arthur G. Cooke, m.a. 
(Cantab.), Lecturer on Physics and Electric Engineering 
at the Battersea (London) Polytechnic ; and W. J. Dibdin, 
f.i.c, f.c.s., late Chemist and Superintending Gas Ex- 
aminer, London County Council. In Press. 

Gowers. Manual of Diseases of the Nervous System. 
A Complete Text-Book. By Sir William R. Gowers, m.d., f.r.s., Physician to 
National Hospital for the Paralyzed and Epileptic ; Consulting Physician, University 
College Hospital ; formerly Professor of Clinical Medicine, University College, etc. 
Revised and Enlarged. With many new Illustrations. Two volumes. Octavo. 

Vol. I. Diseases of the Nerves and Spinal Cord. 

Third Edition. Cloth, $4.00 ; Sheep, $5.00 ; Half Russia, $6.00 

Vol. II. Brain and Cranial Nerves ; General and Functional 
Diseases. 

Second Edition. Cloth, $4.00 ; Sheep, $5.00 ; Half Russia, $6.00 

*#* This book has been translated into German, Italian, and Spanish. It is pub- 
lished in London, Milan, Bonn, Barcelona, and Philadelphia. 

Syphilis and the Nervous System. 

Being a Revised Reprint of the Lettsomian Lectures for 1890, delivered before 
the Medical Society of London. i2mo. Cloth, $1.00 

Epilepsy and Other Chronic Convulsive Diseases. 

Their Causes, Symptoms, and Treatment Second Edition. Cloth, $3.00 

Hadley. General Medical and Surgical Nursing. 

A Manual for Nurses. By Dr. W. G. Hadley, Physician to, and Lecturer on 
Medicine to the Nurses at, the London Hospital. With an Appendix on Sick-Room 
Cookery. i2mo. 326 pages. Cloth, $1.25 

Haig. Causation of Disease by Uric Acid. Fifth Edition. 

A Contribution to the Pathology of High Arterial Tension, Headache, Epilepsy, 
Mental Depression, Gout, Rheumatism, Diabetes, Bright' s Disease, Anaemia, etc. 
By Alexander Haig, m.a., m.d. (Oxon.), f.r.c.p., Physician to Metropolitan Hos- 
pital, London. 75 Illustrations. Fifth Edition. 8vo. 846 pages. Cloth, $3.00 

Diet and Food. 

Considered in Relation to Strength and Power of Endurance. Third Edition, 
Revised. Cloth, J1.00 



20 P. BLAKISTON'S SON &* CO.'S 

Hall. Diseases of the Nose and Throat. 

By F. de Havilland Hall, m.d., f.r.c.p. (Lond.), Physician to the Westminster 
Hospital ; President of the Laryngological Society of London ; Joint Lecturer on the 
Principles and Practice of Medicine at the Westminster Hospital ; and Herbert 
Tilley, m.d., b.s. (Lond.), f.r.c.s. (Eng.), Surgeon to the Throat Hospital, Golden 
Square ; Lecturer on Diseases of the Nose and Throat, London Post-Graduate College 
and Polyclinic. Second Edition, Thoroughly Revised, with 2 Plates and 80 Illustra- 
tions. Just Ready. Cloth, $2.75 

Hamilton. Lectures on Tumors 

from a Clinical Standpoint. By John B. Hamilton, m.d., ll.d., late Professor of 
Surgery in Rush Medical College, Chicago ; Professor of Surgery, Chicago Polyclinic ; 
Surgeon Presbyterian Hospital, etc. Third Edition, Revised. With New Illustra- 
tions. i2mo. Cloth, $1.25 

Hansell and Reber. Muscular Anomalies or the Eye. 

By Howard F. Hansell, a.m., m.d., Clinical Professor of Ophthalmology, Jefferson 
Medical College ; Professor of Diseases of the Eye, Philadelphia Polyclinic, etc.; and 
Wendell Reber, m.d., Instructor in Ophthalmology, Philadelphia Polyclinic, etc. 
W T ith 1 Plate and 28 other Illustrations. i2mo. Cloth, $1.50 

Hansell and Bell. Clinical Ophthalmology. 

By Howard F. Hansell, a.m., m.d., and James H. Bell, m.d. With Colored Plate 
of Normal Fundus and 120 Illustrations. i2mo. Cloth, $1.50 

Hare. Mediastinal Disease. 

The Pathology, Clinical History, and Diagnosis of Affections of the Mediastinum 
other than those of the Heart and Aorta. By H. A. Hare, m.d., Professor of 
Materia Medica and Therapeutics in Jefferson Medical College. 8vo. Illustrated. 

Cloth, $2.oa 

Harlan. Eyesight 

and How to Care for It. By George C. Harlan, m.d., Professor of Diseases ot 
the Eye, Philadelphia Polyclinic. Illustrated. Cloth, .40 

Harris' Principles and Practice of Dentistry. 

Including Anatomy, Physiology, Pathology, Therapeutics, Dental Surgery, and 
Mechanism. By Chapin A. Harris, m.d., d.d.s., late President of the Baltimore 
Dental College; Author of "Dictionary of Medical Terminology and Dental Sur- 
gery." Thirteenth Edition, Revised and Edited by Ferdinand J. S. Gorgas, 
a.m., m.d., d.d.s., Author of "Dental Medicine;" Professor of the Principle^ of 
Dental Science, Oral Surgery, and Dental Mechanism in the University of Maryland. 
1250 Illustrations. 1 180 pages. 8vo. 

Cloth, $6.00 ; Leather, $7.00 ; Half Russia, $8.00 

Dictionary of Dentistry. 

Including Definitions of such Words and Phrases of the Collateral Sciences as 
Pertain to the Art and Practice of Dentistry. Sixth Edition, Rewritten, Re- 
vised, and Enlarged. By Ferdinand J. S. Gorgas, m.d., d.d.s., Author of 
" Dental Medicine ;" Editor of Harris' "Principles and Practice of Dentistry ;" 
Professor of Principles of Dental Science, Oral Surgery, and Prosthetic Dentistry 
in the University of Maryland. Octavo. Cloth, $5.00 ; Leather, $6.oo- 



MEDICAL AND SCIENTIFIC PUBLICATIONS. 21 

Hartridge. Refraction. 

The Refraction of the Eye. A Manual for Students. By Gustavus Hartridge, 
f.r.c.s., Senior Surgeon Royal Westminster Ophthalmic Hospital; Ophthalmic 
Surgeon to St. Bartholomew's Hospital, etc. 105 Illustrations and Sheet of Test 
Types. Eleventh Edition, Revised and Enlarged. Just Ready. Cloth, $1.50 

On the Ophthalmoscope. 

A Manual for Physicians and Students. Fourth Edition, Revised. With Colored 
Plates and 68 Wood-cuts. i2mo. Just Ready. Cloth, #1.50 

Hartshorne. Our Homes. 

Their Situation, Construction, Drainage, etc. By Henry Hartshorne, m.d. Illus- 
trated. Cloth, .40 

Hatfield. Diseases of Children. 

By Marcus P. Hatfield, Professor of Diseases of Children, Chicago Medical Col- 
lege. With a Colored Plate. Second Edition. Being No. 14 ? Quiz- Comp end ? 
Series. i2mo. Cloth, .80 ; Interleaved for the Addition of Notes, $1.00 

" Dr. Hatfield seems to have most thoroughly appreciated the needs of students, and most 
excellently has he condensed his matter into available form. It is in accord with the most recent 
teachings, and while brief and concise, is surprisingly complete. . . . It is free from irritating 
repetition of questions and answers which mars so many of the compends now in use. Written in 
systematic form, the consideration of each disease begins with its definition, and proceeds through 
the usual subheadings to prognosis and treatment, thus furnishing a complete, readable text-book." 
— Annals of Gynecology and Pediatry. 

Heath. Minor Surgery and Bandaging. 

By Christopher Heath, f.r.c.s., Holme Professor of Clinical Surgery in Univer- 
sity College, London. Twelfth Edition, Revised and Enlarged by Bilton Pollard, 
f.r.c.s., Surgeon University College Hospital, London. With 195 Illustrations, 
Formulas, Diet List, etc. i2mo. Cloth, $1.50 

Practical Anatomy. 

A Manual of Dissections. Eighth London Edition. 300 Illus. Cloth, $4.25 

Clinical Lectures on Surgical Subjects. 

Second series. Delivered at University College Hospital. Just Ready. 

Cloth, $2.00 

Hedley. Therapeutic Electricity and Practical Muscle Testing. 
By W. S. Hedley, m.d., m.r.cs., in charge of the Electrotherapeutic Department 
of the London Hospital. 99 Illustrations. Octavo. Cloth, $2.50 

Heller. Essentials of Materia Medica, Pharmacy, and Prescription 
Writing. 

By Edwin A. Heller, m.d., Quiz-Master in Materia Medica and Pharmacy at the 
Medical Institute, University of Pennsylvania. i2mo. Cloth, 51.50 

Henry. Anaemia. 
A Practical Treatise. By Fred'k P. Henry, m.d., Physician to Episcopal Hospital, 
Philadelphia. Half Cloth, .50 

Heusler. The Terpenes. 
By Fr. Heusler, ph.d., Privatdocent of Chemistry in the University at Bonn. 
Authorized Translation and Revision by F. J. Pond, ph.d., Assistant Professor of 
Chemistry, Pennsylvania State College. Cloth, $4.00 



22 P. BLAKISTON'S SON &* CO.' S 

Hemmeter. Diseases of the Stomach. Third Edition. 

Their Special Pathology, Diagnosis, and Treatment. With Sections on Anatomy, 
Analysis of Stomach Contents, Dietetics, Surgery of the Stomach, etc. By John C. 
Hemmeter, m.d., philos.d., Professor in the Medical Department of the University 
of Maryland ; Consultant to the University Hospital ; Director of the Clinical Labor- 
atory, etc. ; formerly Clinical Professor of Medicine at the Baltimore Medical College, 
etc. Third Edition, Revised. With 15 Plates and 41 other Illustrations, some of 
which are in Colors. Cloth, $6.00; Leather, $7.00; Half Russia, $8.00 

Diseases of the Intestines. 

A Complete Systematic Treatise on Diseases of the Intestines, including their 
Special Pathology, Diagnosis, and Treatment, with Sections on Anatomy and 
Physiology, Microscopic and Chemic Examination of the Intestinal Contents, 
Secretions, Feces, and Urine. Intestinal Bacteria and Parasites ; Surgery of the 
Intestines ; Dietetics, Diseases of the Rectum, etc. With many Full-page Plates, 
Colored and other Illustrations, most of which are Original. 2 vols. Octavo. 
Just Ready. Vol. I. Cloth, $5.00; Sheep, $6.00 

Vol. II. Cloth, $5.00; Sheep, $6.00 
The Section on Anatomy has been prepared by Dr. J. Holmes Smith, Associate 
Professor and Demonstrator of Anatomy, and Lecturer on Clinical Surgery, University 
of Maryland, Baltimore. The Section on Bacteria of the Intestines has been 
prepared by Dr. Wm. Royal Stokes, Associate Professor of Pathology and Bacteriology, 
and Visiting Pathologist to the University Hospital, University of Maryland, Baltimore. 
The Section on Diseases of the Rectum has been prepared by Dr. Thomas C. 
Martin, Professor of Proctology, Cleveland College of Physicians and Surgeons. The 
Section on Examination of Urine and Feces has been prepared by Dr. Harry 
Adler, Demonstrator of Clinical Pathology, Associate Professor of Diseases of the 
Stomach and Intestines, University of Maryland, Baltimore. The Illustrations form 
a most useful and practical series of pictures, — nearly all have been reproduced from 
pathological preparations and original drawings, a few being printed in several colors. 

Hewlett. Manual of Bacteriology. 75 Illustrations. 

By R. T. Hewlett, m.d., m.r.c.p., Assistant Bacteriologist British Institute of Pre- 
ventive Medicine, etc. Second Edition, Revised. Just Ready. Cloth, $4.00 

Hollopeter. Hay Fever and Its Successful Treatment. 

By W. C. Hollopeter, a.m., m.d., Clinical Professor of Pediatrics in the Medico- 
Chirurgical College of Philadelphia ; Physician to the Methodist Episcopal, Medico- 
Chirurgical, and St. Joseph's Hospitals, etc. Second Edition. i2mo. Cloth, $1.00 

Holden's Anatomy. Seventh Edition. 

A Manual of the Dissections of the Human Body. By John Langton, f.r.c.S., 
Surgeon to, and Lecturer on Anatomy at, St. Bartholomew's Hospital. Carefully 
Revised by A. Hewson, m.d., Demonstrator of Anatomy, Jefferson Medical College, 
Philadelphia, etc. 320 Illustrations. Two small compact volumes. i2mo. 

Vol. I. Scalp, Face, Orbit, Neck, Throat, Thorax, Upper Extremity. 435 pages. 

153 Illustrations. Oil Cloth, $1.50 

Vol. II. Abdomen, Perineum, Lower Extremity, Brain, Eye, Ear, Mammary 

Gland, Scrotum, Testes. 445 pages. 167 Illustrations. 

Oil Cloth, $1.50 

Human Osteology. 

Comprising a Description of the Bones, with Colored Delineations of the Attach- 
ments of the Muscles. The General and Microscopical Structure of Bone and 
its Development. Eighth Edition, Carefully Revised. Edited by Charles 
Stewart, f.r.s., and R. W. Reid, m.d., f.r.c.S. With Colored Lithographic 
Plates and Numerous Illustrations. Cloth, $5.25 

Landmarks. 

Medical and Surgical. Fourth Edition. 8vo. Cloth, .75 



MEDICAL AND SCIENTIFIC PUBLICATIONS. 23 

Holland. The Urine, the Gastric Contents, the Common Poisons, 
and the Milk. Illustrated. 
Memoranda (Chemical and Microscopical) for Laboratory Use. By J. W. Holland, 
m.d., Professor of Medical Chemistry and Toxicology in Jefferson Medical College 
of Philadelphia. Sixth Edition, Enlarged. Illustrated and Interleaved. i2mo. 

Horwitz's Compend of Surgery. cloth - * IO ° 

Including Minor Surgery, Amputations, Bandaging, Fractures, Dislocations, Surgical 
Diseases, etc., with Differential Diagnosis and Treatment. By Orville Horwitz, 
b.s., m.d., Professor of Genito-Urinary Diseases, late Demonstrator of Surgery, 
Jefferson Medical College. Fifth Edition. 167 Illustrations and 98 Formulae. i2mo. 
No. g ? Quiz- Compend ? Series. Cloth, .80; Interleaved for Notes, $1.00 

*.£* A Spanish translation of this book has recently been published in Barcelona. 

Horsley. The Brain and Spinal Cord, 
the Structure and Functions of. By Victor A. Horsley, m.b., f.r.s., etc., As- 
sistant Surgeon University College Hospital, London, etc. Illustrated. Cloth, $2.50 

Hovell. Diseases of the Ear and Naso-Pharynx. 

A Treatise including Anatomy and Physiology of the Organ, together with the treat- 
ment of the affections of the Nose and Pharynx which conduce to aural disease. By 
T. Mark Hovell, f.r.c.s. (Edin.), m.r.c.s. (Eng.), Aural Surgeon to the London 
Hospital for Diseases of the Throat, etc. 128 Illus. Second Edition. Cloth, $5.50 

Humphrey. A Manual for Nurses. Twenty-third Edition. 

Including General Anatomy and Physiology, Management of the Sick-room, etc. By 
Laurence Humphrey, m.a., m.b., m.r.c.s., Assistant Physician to Addenbrook's 
Hospital, Cambridge, England. 23d Edition. i2mo. 79 Illustrations. Cloth, $1.00 

Hughes and Keith. Dissections. Illustrated. 

A Manual of Dissections by Alfred W. Hughes, m.b., m.r.c.s. (Edin.), late Pro- 
fessor of Anatomy and Dean of Medical Faculty, King's College, London, etc., and 
Arthur Keith, m.d., Lecturer on Anatomy, London Hospital Medical College, etc. 
In three parts, with many Colored and other Illustrations. 

I. Upper and Lower Extremity. 38 Plates, 1 16 other Illustrations. Just Ready. 

Cloth, $3.00 
II. Abdomen. Thorax. 4 Plates, 149 other Illus. Just Ready. Cloth, $3.00 
III. Head, Neck, and Central Nervous System. 16 Plates and 204 other Illustra- 
tions. Just Ready. Cloth, $3.00 

Hughes. Compend of the Practice of Medicine. Sixth Edition. 

Giving the Synonyms, Definition, Causes, Symptoms, Pathology, Prognosis, Diag- 
nosis, Treatment, etc., of each Disease. The Treatment is especially full and a 
number of valuable Prescriptions have been incorporated. Sixth Edition, Revised 
and Enlarged. By Daniel E. Hughes, m.d., Chief Resident Physician Philadel- 
phia Hospital ; formerly Demonstrator of Clinical Medicine at Jefferson Medical 
College, Philadelphia. Being Nos. 2 and 3 f Quiz-Competid? Series. 

Quiz-Compend Edition, in two Parts. 

Part I. — Continued, Eruptive, and Periodical Fevers, Diseases of the Mouth, 
Stomach, Intestines, Peritoneum, Biliary Passages, Liver, Kidneys, Blood, etc., 
Parasites, etc., and General Diseases, etc. 

Part II. — Physical Diagnosis, Diseases of the Respiratory System, Circulatory 
System, Diseases of the Brain and Nervous System, Mental Diseases, etc. 

Price of each Part, in Cloth, .80 ; Interleaved for the Addition of Notes, $1.00 

Physicians' Edition. 

In one volume, including the above two parts, a Section on Skin Diseases, and 
an Index. Sixth Revised and E?ilarged Edition. 623 pages. 

Full Morocco, Gilt Edges, Round Corners, $2.25 



24 P. BLAKISTON'S SON &* CO.' S 

Ireland. The Mental Affections of Children. 

Idiocy, Imbecility, Insanity, etc. By W. W. Ireland, m.d. (Edin.), of the Home 
and School for Imbeciles, Mavisbush, Scotland ; Second Edition, Revised and En- 
larged, Cloth, $4.00 

Jacoby. Electrotherapy. Illustrated. 
See Cohen, Physiologic Therapeutics, page 9. 

Jacobson. The Operations of Surgery. 

By W. H. A. Jacobson, f.r.cs. (Eng.), Surgeon Guy's Hospital, etc., and F. J. 
Steward, f.r.cs., Assistant Surgeon Guy's Hospital and the Hospital for Sick Chil- 
dren, Great Ormand Street, London. With 550 Illustrations. Fourth Edition, 
Revised and Enlarged. Two volumes. Octavo. 1524 pages. 

Cloth, $10.00; Leather, $12.00 

Jennings. A Manual of Ophthalmoscopy. 

By J. E. Jennings, m.d. (Univ. Penna.), Formerly Clinical Assistant Royal London 
Ophthalmic Hospital, London ; Fellow of the British Laryngological and Rhinological 
Association ; Member of the American Medical Association ; Member of the St. 
Louis Medical Society, etc. With 95 Illustrations and 1 Colored Plate. Just Ready. 

Cloth, $1.50 

Jones. Medical Electricity. Third Edition. 

A Practical Handbook for Students and Practitioners of Medicine. By H. Lewis 
Jones, m.a., m.d., f.r.c.p., Medical Officer in Charge Electrical Department, St. 
Bartholomew's Hospital. Third Edition of Steavenson and Jones' Medical Elec- 
tricity, Revised and Enlarged. 1 1 7 Illustrations. 532 pages. i2mo. Cloth, $3.00 

Jones. Outlines of Physiology. 

By Edward Groves Jones, m.d., Assistant Professor of Physiology and Pathological 
Anatomy, Atlanta College of Physicians and Surgeons. 96 Illustrations. i2mo. 

Cloth, $1.50 

Keay. Gall-Stones. 

The Medical Treatment of Gall-Stones. By J. H. Keay, m.a., m.d., Physician to 
Trinity Hospital, Greenwich, London. i2mo. Just Ready. Cloth, $1.25 

Keen. Clinical Charts. 

A Series of Seven Outline Drawings of the Human Body, on which may be marked 
the course of any Disease, Fractures, Operations, etc. By W. W. Keen, m.d., 
Professor of the Principles of Surgery and Clinical Surgery, Jefferson Medical College. 
Each Drawing may be had separately gummed on back for pasting in case book. 
25 to the pad. Price, 25 cents. Special Charts will be printed to order. Samples free. 

Kehr. Diagnosis of Gall-Stone Disease. 

Including one hundred Clinical and Operative Cases illustrating Diagnostic Points of 
the Different Forms of the Disease. By Prof. Dr. Hans Kehr, of Halberstadt. 
Authorized Translation by William Wotkyns Seymour, a.b. (Yale), m.d. (Harvard), 
of Troy, N. Y. i2mo. 370 pages. Cloth, $2.50 

Kenwood. Public Health Laboratory Work. 

By H. R. Kenwood, m.b., d.p.h., f.c.s., Assistant Professor of Public Health, 
University College, London, etc. 116 Illustrations and 3 Plates. Cloth, $2.00 



MEDICAL AND SCIENTIFIC PUBLICATIONS. 25 

Kirkes' Physiology. Seventeenth Edition. 

{The only Authorized Edition. i2mo. Dark Red Cloth.) A Handbook of Physiology. 
Sixteenth London Edition, Revised and Enlarged. By W. D. Halliburton, m.d., 
F.R.S., Professor of Physiology, King's College, London. Thoroughly Revised and 
in many parts Rewritten. 68 1 Illustrations, a number of which are printed in Colors. 
888 pages. i2mo. Cloth, $3.00; Leather, $3.75 

IMPORTANT NOTICE. This is the identical Edition of " Kirkes' Physiology," as published in 

, — London by John Murray, the sole owner of the book, and containing 

the revisions and additions of Dr. Halliburton, and the new and original illustrations incfuded at 
his suggestion. This edition has been carefully and thoroughly revised. 

Kleen. Diabetes Mellitus and Glycosuria. 

Their Diagnosis and Treatment. By Dr. Emil Kleen. Octavo. Cloth, $2.50 

Knight. Diseases of the Throat. 
A Manual for Students. By Charles H. Knight, m.d., Professor of Laryngology, 
Cornell University Medical College ; Surgeon to Throat Department, Manhattan Eye 
and Ear Hospital, etc. Illustrated. Nearly Ready. 

Knopf. Pulmonary Tuberculosis. Its Modern Prophylaxis and the 
Treatment in Special Institutions and at Home. 

By S. A. Knopf, m.d., Physician to the Lung Department of the New York Throat 
and Nose Hospital ; former Assistant Physician to Professor Dettweiler, Falkenstein 
Sanatorium, Germany, etc. Illustrated. Octavo. Cloth, $3.00 

Landis' Compend of Obstetrics. 

Especially adapted to the Use of Students and Physicians. By Henry G. Landis, 
m.d. Seventh Edition, Revised by Wm. H. Wells, m.d., Demonstrator of Clinical 
Obstetrics, Jefferson Medical College ; Member Obstetrical Society of Philadelphia, 
etc. With 52 Illustrations. No. j ? Quiz- Compend? Series. Just Ready. 

Cloth, .80 ; Interleaved for the Addition of Notes, $1.00 

Landois. A Text-Book of Human Physiology. 

Including Histology and Microscopical Anatomy, with Special Reference to the Re- 
quirements of Practical Medicine. By Dr. L. Landois, Professor of Physiology and 
Director of the Physiological Institute in the University of Greifswald. Fifth Ameri- 
can translated from the last German Edition, with Additions, by Wm. Stirling, 
m.d., d.Sc, Brackenbury Professor of Physiology and Histology in Owens College, 
and Professor in Victoria University, Manchester ; Examiner in Physiology in Uni- 
versity of Oxford, England. With 845 Illustrations, many of which are printed in 
Colors. 8vo. In Press. 

Lazarus-Barlow. General Pathology. 

By W. S. Lazarus-Barlow, m.d., Demonstrator of Pathology at the University of 
Cambridge, England. 795 pages. Octavo. Cloth, $5.00 

Lee. The Microtomist's Vade Mecum. Fifth Edition. 

A Handbook of the Methods of Microscopic Anatomy. By Arthur Bolles Lee, 
formerly Assistant in the Russian Laboratory of Zoology at Villefranche-sur-Mer (Nice). 
894 Articles. Enlarged, Revised, and Rearranged. 532 pages. 8vo. Cloth, $4.00 

LefFmann and Beam. Food Analysis. Illustrated. 
Select Methods in Food Analysis. By Henry Leffmann, m.d., Professor of Chem- 
istry in the Woman's Medical College of Pennsylvania and in the Wagner Free 
Institute of Science ; Pathological Chemist, Jefferson Medical College Hospital, Phila- 
delphia ; Vice-President (190 1 ) Society Public Analysts, etc.; and William Beam, 
a.m. With many useful Tables, 4 Plates and 53 other Illustrations. i2mo. 

Cloth, $2.50 



26 P. BLAKISTON'S SON &- CO: S 

Leffmann. Compend of Medical Chemistry. 

Inorganic and Organic. Including Urine Analysis. By Henry Leffmann, m.d., 
Professor of Chemistry in the Woman's Medical College of Pennsylvania and in the 
Wagner Free Institute of Science, Philadelphia ; Pathological Chemist Jefferson Medi- 
cal College Hospital ; Vice-President, 1901, Society of Public Analysts, etc. No. 10 
? Quiz- Co7np end ? Series. Fourth Edition, Rewritten. 

Cloth, .80 ; Interleaved for the Addition of Notes, $1.00 

The Coal-Tar Colors. 

With Special Reference to their Injurious Qualities and the Restrictions of their 
Use. A Translation of Theodore Weyl's Monograph. i2mo. Cloth, $1.25 

Examination of Water 

for Sanitary and Technical Purposes. Fourth Edition, Enlarged. Illustrated. 
i2mo. Cloth, $1.25 

Analysis of Milk and Milk Products. 

Arranged to suit the needs of Analytical Chemists, Dairymen, and Milk Inspec- 
tors. Second Edition, Revised and Enlarged. Illustrated. i2mo. Cloth, $1.25 

Handbook of Structural Formulae 

for the Use of Students, containing 180 Structural and Stereo-chemic Formulae. 
i2mo. Interleaved.. Cloth, $1.00 

Lewers. On the Diseases of Women. 

A Practical Treatise. By Dr. A. H. N. Lewers, Assistant Obstetric Physician to 
the London Hospital. 146 Engravings. Fifth Edition, Revised. Cloth, $2.50 

Lewis (Bevan). Mental Diseases. 

A Text-Book having Special Reference to the Pathological Aspects of Insanity. By 
Bevan Lewis, l.r.c.p., m.r.c.s., Medical Director West Riding Asylum, Wake- 
field, England. 26 Lithograph Plates and other Illustrations. Second Edition, Re- 
vised and Enlarged. 8vo. Cloth, $7.00 

Lincoln. School and Industrial Hygiene. 

By D. F. Lincoln, m.d. Cloth, .40 

Longley's Pocket Medical Dictionary. 

Giving the Definition and Pronunciation of Words and Terms in General Use in 
Medicine. With an Appendix, containing Poisons and their Antidotes, Abbreviations 
Used in Prescriptions, etc. By Elias Longley. Cloth, .75 ; Tucks and Pocket, $1.00 

Macalister's Human Anatomy. 816 Illustrations. 

Systematic and Topographical, including the Embryology, Histology, and Mor- 
phology of Man. With Special Reference to the Requirements of Practical Surgery 
and Medicine. By Alex. Macalister, m.d., f.r.s., Professor of Anatomy in the 
University of Cambridge. 816 Illustrations. Octavo. Cloth, $5.00 ; Leather, $6.00 

McBride. Diseases of the Throat, Nose, and Ear. 

A Clinical Manual for Students and Practitioners. JBy P. McBride, m.d., f.r.cp. 
(Edin.), Surgeon to the Ear and Throat Department of the Royal Infirmary ; Lec- 
turer on Diseases of Throat and Ear, Edinburgh School of Medicine, etc. With 
Colored Illustrations from Original Drawings. Third Edition. Thoroughly Revised 
and Enlarged. Octavo. Handsome Cloth, Gilt Top, $7.00 

McCook. American Spiders and Their Spinning Work. 
A Natural History of the Orbweaving Spiders of the United States. By Henry C. 
McCook, d.d., Vice-President of the Academy of Natural Sciences of Philadelphia ; 
Member Entomological Society ; Author of "The Agricultural Ants of Texas," etc. 
Three volumes. Handsomely Illustrated. Cloth, $40.00 



MEDICAL AND SCIENTIFIC PUBLICATIONS. 27 

Macready. A Treatise on Ruptures. 

By Jonathan F. C. H. Macready, f.r.c.s., Surgeon to the Great Northern Central 
Hospital ; to the City of London Hospital for Diseases of the Chest, etc. 24 Full- 
page Plates and Wood Engravings. Octavo. Cloth, $6.00 

McFarland. Prophylaxis — Personal Hygiene — Nursing and Care of 
the Sick. 
See Cohen, Physiologic Therapeutics, page 10. 

McMurrich. A Manual of Embryology. 

By J. Playfair McMurrich, a.m., ph.d., Professor of Anatomy, Medical Depart- 
ment of the University of Michigan, Ann Arbor. 276 Illustrations. Just Ready. 

Makins. Surgical Experiences in South Africa, 1 899-1900. 

Being mainly a Clinical Study of the Effects of Injuries Produced by Bullets of Small 
Calibre. By George Henry Makins, f.r.c.s., Surgeon to St. Thomas's Hospital, 
London ; Joint Lecturer on Surgery in the Medical School of St. Thomas's Hospital ; 
and late one of the Consulting Surgeons to the South African Field Force. With 25 
Plates and 96 other Illustrations. Octavo. Cloth, $4.00 

Mann. Forensic Medicine and Toxicology. 

By J. Dixon Mann, m.d., f.r.c.p., Professor of Medical Jurisprudence and Toxi- 
cology- in Owens College, Manchester ; Examiner in Forensic Medicine in University 
of London, etc. Illustrated. Octavo. Cloth, $6.50 

Mann's Manual of Psychological Medicine 

and Allied Nervous Diseases. Their Diagnosis, Pathology, Prognosis, and Treat- 
ment, including their Medico-Legal Aspects. With Chapter on Expert Testimony and 
an Abstract of the Laws Relating to the Insane in all the States of the L nion. By 
Edward C. Mann, m.d. With Illustrations. Octavo. Cloth, S3. 00 

Marshall's Physiological Diagrams, Life Size, Colored. 

Eleven Life-size Diagrams (each 7 feet by 3 feet 7 inches). Designed for Demon- 
stration before the Class. By John Marshall, f.r.s., f.r.c.s., Professor of 
Anatomy to the Royal Academy ; Professor of Surgery, University College, London, 
etc. In Sheets, $40.00 ; Backed with Muslin and Mounted on Rollers, $60.00 

Ditto, Spring Rollers, in Handsome Walnut Map Case, $100.00 
Single Plates, Sheets, $5.00 ; Mounted, $7. 50 ; Explanatory Key, 50 cents. 

Purchaser must pay freight charges. 

No. 1 — The Skeleton and Ligaments. No. 2 — The Muscles and Joints, with Ani- 
mal Mechanics. No. 3 — The Viscera in Position. No. 4 — The Heart and Principal 
Blood-vessels. No. 5 — The Lymphatics. No. 6 — The Digestive Organs. No. 7 — The 
Brain and Nerves. Nos. 8 and 9 — The Organs of the Senses. Nos. 10 and 11 — The 
Microscopic Structure of the Textures and Organs. {Send for Special Circular.') 

Maxwell. Terminologia Medica Polyglotta. 

By Dr. Theodore Maxwell. Octavo. Cloth, $3.00 

The object of this work is to assist the medical men of any nationality in reading medical 
literature written in a language not their own. Each term is usually given in seven languages, 
viz. : English, French, German, Italian, Spanish, Russian, and Latin. 

Maylard. The Surgery of the Alimentary Canal. 

By Alfred Ernest Maylard, m.b., b.s., Senior Surgeon to the Victoria Infirmary, 
Glasgow. Second Edition. 97 Illustrations. Octavo. Cloth, S3. 00 

Mays' Theine in the Treatment of Neuralgia. 
By Thomas J. Mays, m.d. i6mo. y 2 bound, .50 



28 P. BLAKISTON'S SON &- CO: S 

Memminger. Diagnosis by the Urine. 
The Practical Examination of Urine, with Special Reference to Diagnosis. By 
Allard Memminger, m.d., Professor of Chemistry and Hygiene ; Clinical Professor 
of Urinary Diagnosis in the Medical College of the State of South Carolina ; Visiting 
Physician in the City Hospital of Charleston, etc. Second Edition, Enlarged and 
Revised. 24 Illustrations. i2mo. Cloth, $1.00 

Minot. Embryology. 

A Laboratory Text-Book of Embryology. By Charles S. Minot, s.d., ll.d., Pro- 
fessor of Histology and Human Embryology, Harvard University Medical School. 
Illustrated. Nearly Ready. 

Montgomery. A Text-Book of Practical Gynecology. 
By Edward E. Montgomery, m.d., Professor of Gynecology in Jefferson Medical 
College, Philadelphia; Gynecologist to the Jefferson and St. Joseph's Hospitals, etc. 
527 Illustrations, many of which are from original sources. 800 pages. Octavo. 

Cloth, $5.00 ; Leather, $6.00 

*£* This is a systematic modern treatise on Diseases of Women. The author's 
aim has been to produce a book that will be thorough and practical in every particular. 
The illustrations, nearly all of which are from original sources, have for the most part 
been drawn by special artists. 

" The author has a clear conception of his subject ; this, with his manner of treatment, intro- 
duces the reader to questions otherwise intricate in such a manner as to make them easily compre- 
hended. His introduction, together with his comments on diagnosis and examination of the 
patient are delightfully clear and instructive. Therapeutics, local and systematic, are clearly and 
intelligently discussed." — Brooklyn Medical Journal. 

Morris. Text-Book of Anatomy. Third Edition. 846 Illustra- 
tions, 267 in Colors. 

A Complete Text-Book. Edited by Henry Morris, f.r.c.s., Surgeon to, and Lec- 
turer on Anatomy at, Middlesex Hospital, assisted by J. Bland Sutton, f.r.c.s., 
J. H. Davies-Colley, f.r.c.s., Wm. J. Walsham, f.r.c.s., H. St. John Brooks, 
m.d., R. Marcus Gunn, f.r.c.s., Arthur Hensman, f.r.c.s., Frederick Treves, 
f.r.c.s., William Anderson, f.r.c.s., Arthur Robinson, m.d., m.r.c.s., and 
Prof. W. H. A. Jacobson. One Handsome Octavo Volume, with 846 Illustrations, 
of which 267 are printed in Colors. Thumb Index and Colored Illustrations in all 
Copies. Cloth, $6.00 ; Leather, $7.00 ; Half Russia, $8.00 

" Of all the text-books of moderate size on human anatomy in the English language, Morris 
is undoubtedly the most up-to-date and accurate. . . . For the student, the surgeon, or for the 
general practitioner who desires to review his anatomy, Morris is decidedly the book to buy." — 
The Philadelphia Medical Journal. 

%* Morris' Anatomy is now the recognized standard text-book in a large number 
of medical schools throughout the United States, England, and Canada. It is in many 
respects the best book for students' use, and in its present edition is the latest and best 
illustrated of all books on anatomy. The revisions have been carefully made and 
edited, several sections having been almost entirely rewritten, old illustrations replaced 
and new ones added, a larger number being printed in colors. 

Renal Surgery. 

With Special Reference to Stone in the Kidney and Ureter, and to the Surgical 
Treatment of Calculous Anuria, together with a Critical Examination of Sub- 
parietal Injuries of the Ureter. Illustrated. 8vo. Cloth, $2.00 

Mitchell and Gulick. Mechanotherapy. 
See Cohen, Physiologic Therapeutics, page 10. 



MEDICAL AND SCIENTIFIC PUBLICATIONS. 29 

Morton on Refraction of the Eye. 

Its Diagnosis and the Correction of its Errors. With Chapter on Keratoscopy and 
Test Types. By A. Morton, m.b. Sixth Edition, Revised. Cloth, $1.00 

Moullin. Surgery. Third Edition, by Hamilton. 

A Complete Text-Book. By C. W. Mansell Moullin, m.a., m.d. (Oxon.), f.r.c.s., 
Surgeon and Lecturer on Physiology to the London Hospital ; formerly Radcliffe 
Traveling Fellow and Fellow of Pembroke College, Oxford. Third American 
Edition, Revised and Edited by the late John B. Hamilton, m.d., ll.d., Professor 
of the Principles of Surgery and Clinical Surgery, Rush Medical College, Chicago ; 
Professor of Surgery, Chicago Polyclinic ; Surgeon, formerly Supervising Surgeon- 
General, U. S. Marine Hospital Service ; Surgeon to Presbyterian Hospital. 600 
Illustrations, over 200 of which are original, and many of which are printed in 
Colors. Octavo. 1250 pages. Cloth, $6.00; Leather, $7.00; Half Russia, $8.00 

Enlargement of the Prostate. 

Its Treatment and Radical Cure. Illustrated. Second Edition, Enlarged. 
Octavo. Cloth, $1.75 

Inflammation of the Bladder and Urinary Fever. 

Octavo. Cloth, $1.50 

Murray. Rough Notes on Remedies. 

By Wm. Murray, m.d., f.r.c.p. (Lond.), Consulting Physician Newcastle-on-Tyne 
Hospital for Sick Children. Fourth Edition, Enlarged. Crown 8vo. Cloth, $1.25 

Muter. Practical and Analytical Chemistry. 

By John Muter, f.r.s., f.c.s., etc. Second American from the Eighth English 
Edition. Revised to meet the Requirements of American Medical and Pharma- 
ceutical Colleges. 56 Illustrations. Cloth, $1.25 

New Sydenham Society Publications. 

From three to six volumes published each year. List of Volumes upon application. 

Per annum, #8.00 

Notter. The Theory and Practice of Hygiene. Second Edition. 
A Complete Treatise by J. Lane Notter, m.a., m.d., f.c.s., Fellow and Member 
of Council of the Sanitary Institute of Great Britain ; Professor of Hygiene, Army 
Medical School ; Examiner in Hygiene, University of Cambridge, etc.; and W. H. 
Horrocks, m.d., b. Sc. (Lond.), Assistant Professor of Hygiene, Army Medical 
School, Netley. Illustrated by 15 Lithographic Plates and 138 other Illustrations, 
and including many Useful Tables. Second Edition, Carefully Revised. Octavo. 
1085 pages. Cloth, $7.00 

Oertel. Medical Microscopy. 

A Guide to Diagnosis, Elementary Laboratory Methods, and Microscopic Technic. 
By T. E. Oertel, m.d., Professor of Pathology and Clinical Microscopy, Medical 
Department, University of Georgia. 121110. 120 Illustrations. Nearly Ready. 

Oettel. Practical Exercises in Electro-Chemistry. 

By Dr. Felix Oettel. Authorized Translation by Edgar F. Smith, m.a., Professor 
of Chemistry, University of Pennsylvania. Illustrated. Cloth, .75 

Introduction to Electro-Chemical Experiments. 

Illustrated. By same Author and Translator. Cloth, .75 



30 P. BLAKISTON'S SON 6- CO.'S 

Ohlemann. Ocular Therapeutics for Physicians and Students. 

By M. Ohlemann, m.d., late Physician in the Ophthalmological Clinical Institute, 
Royal Prussian University of Berlin, etc. Translated and Edited by Charles A. 
Oliver, a.m., m.d., Attending Surgeon to the Wills Eye Hospital ; Ophthalmic Surgeon 
to the Philadelphia and to the Presbyterian Hospitals. i2mo. Cloth, $1.75 

Ormerod. Diseases of Nervous System. 

By J. A. Ormerod, m.d. (Oxon.), f.r.c.p., Physician to National Hospital for the 
Paralyzed and Epileptic, London. 66 Wood Engravings. i2mo. Cloth, $1. 00 

Osgood. The Winter and Its Dangers. 
By Hamilton Osgood, m.d. Cloth, .40 

Ostrom. Massage and the Original Swedish Movements. 

Their Application to Various Diseases of the Body. A Manual for Students, Nurses, 
and Physicians. By Kurre W. Ostrom, from the Royal University of Upsala, 
Sweden, Formerly Instructor in Massage and Swedish Movements in the Hospital of 
the University of Pennsylvania and in the Philadelphia Polyclinic and College for 
Graduates in Medicine, etc. Fifth Edition, Enlarged. 1 1 5 Illustrations, many of 
which were drawn especially for this purpose. i2mo. Just Ready. Cloth, $1.00 

Packard's Sea Air and Sea Bathing. 

By John H. Packard, m.d. Cloth, .40 

Parkes. Hygiene and Public Health. 

A Practical Manual. By Louis C. Parkes, m.d., d.p.h. (Lond. Univ.), Lecturer 

. on Public Health at St. George's Hospital; Medical Officer of Health and Public 
Analyst, Borough of Chelsea, London, etc.; and Henry Kenwood, m.b., f.cs., 
Assistant Professor of Public Health, University College, London, etc. Sixth Edition, 
Enlarged and Revised. 85 Illustrations. i2mo. Just Ready. Cloth, #3.00 

" The style is good ; dry facts, laws, and statistics are put in such a way that the reader does 
not tire of them and yet rinds them easy to iemember. " — University Medical Magazine. 

The Elements of Health. 

An Introduction to the Study of Hygiene. Illustrated. Cloth, $1.25 

Parsons. Elementary Ophthalmic Optics. 

By J. Herbert Parsons, m.b., m.r.c.s., Clinical Assistant, Royal London Ophthal- 
mic Hospital. With Diagrammatic Illustrations. Just Ready. Cloth, $2.00 

Pershing. The Diagnosis of Nervous and Mental Diseases. 

By Howell T. Pershing, m.d., Professor of Nervous and Mental Diseases in the 
University of Denver; Neurologist to St. Luke's Hospital; Consultant in Nervous 
and Mental Diseases to the Arapahoe County Hospital ; Member of the American 
Neurological Association. With colored and other Illustrations. Cloth, $1.25 

Phillips. Spectacles and Eyeglasses. 
Their Prescription and Adjustment. By R. J. Phillips, m.d., Instructor in Diseases 
of the Eye, Philadelphia Polyclinic ; Ophthalmic Surgeon, Presbyterian Hospital. 
Second Edition, Revised and Enlarged. 49 Illustrations. i2mo. Cloth, $1. 00 



MEDICAL AND SCIENTIFIC PUBLICATIONS. 31 

The Physician's Visiting List. 

Published Annually. Fifty-Second Year (1903) of its Publication. 

Hereafter all styles will contain the interleaf or special memoranda page, except 
the Monthly Edition, and the sizes for 75 and 100 Patients will come in two volumes 
only. 

REGULAR EDITION. 

Tucks, pocket and pencil, Gilt Edges, $1.00 

1.25 
f Jan. to June ) ti 
( July to Dec. J 
J Jan. to June 
( July to Dec. 
Jan. to June 
July to Dec. 



• 25 Patients 


W 


eekly. 


50 




* * 


50 




" 2 vols. 


75 




*' 2 vols. 


IOO 




" 2 vols. 



2.00 



Perpetual Edition, 

without Dates and with Special Memorandum Pages. 

For 25 Patients, Interleaved, Tucks, Pocket, and Pencil, $1.25 
For 50 Patients, Interleaved, Tucks, Pocket, and Pencil, Si. 50 

Monthly Edition, without Dates. 

Can be commenced at any time and used until full. Requires only one writing 
of patient's name for the whole month. 
Plain binding, without Flap or Pencil, . 75 ; Leather cover, Pocket and Pencil, $1.00 

Extra Pencils 

will be sent, postpaid, for 25 cents per half dozen. 

f£T* This list combines the several essential qualities of strength, compactness, 
durability, and convenience. It is made in all sizes and styles to meet the wants of all 
physicians. It is not an elaborate, complicated system of keeping accounts, but a 
plain, simple record, that may be kept with the least expenditure of time and trouble — 
hence its popularity. A special circular, descriptive of contents, will be sent upon 
application. 

Potter. A Handbook of Materia Medica, Pharmacy, and Thera- 
peutics. Ninth Edition, Enlarged. 

Including the Action of Medicines, Special Therapeutics of Disease, Official and 
Practical Pharmacy, and Minute Directions for Prescription Writing, etc. Including 
over 650 Prescriptions and Formulae. By Samuel O. L. Potter, m.a., m.d., m.r.c.p. 
(Lond.), formerly Professor of the Principles and Practice of Medicine, Cooper Medical 
College, San Francisco ; Major and Brigade Surgeon, U. S. Vol. Ninth Edition, 
Revised and Enlarged. 8vo. Just Ready. 
With Thumb Index in each copy. Cloth, $5.00 ; Leather, $6.00 ; Half Russia, $7.00 

Compend of Anatomy, including Visceral Anatomy. 

Sixth Edition, Revised and greatly Enlarged. With 16 Lithographed Plates 
and 117 other Illustrations. Being No. 1 ? Quiz- Compend ? Series. 

Cloth, .80; Interleaved for Taking Notes, $1.00 

Compend of Materia Medica, Therapeutics, and Prescription 

Writing. 

With Special Reference to the Physiological Action of Drugs. Sixth Revised and 
Improved Edition, with Index. Being A 0. 6 f Quiz- Compend ? Series. 

Cloth, .80 ; Interleaved for Taking Notes, $1.00 



32 P. BLAKISTON'S SON &- CO.' S 

Potter. Speech and Its Defects. 

Considered Physiologically, Pathologically, and Remedially ; being the Lea Prize 
Thesis of Jefferson Medical College, 1882. Revised and Corrected. Cloth, $1.00 

Power. Surgical Diseases of Children 

and their Treatment by Modern Methods. By D'Arcy Power, m.a., f.r.c.s. 
(Eng.), Demonstrator of Operative Surgery, St. Bartholomew's Hospital; Surgeon 
to the Victoria Hospital for Children. Illustrated. i2mo. Cloth, $2.50 

Preston. Hysteria and Certain Allied Conditions. 

Their Nature and Treatment. With Special Reference to the Application of the Rest 
Cure, Massage, Electrotherapy, Hypnotism, etc. By George J. Preston, m.d., 
Professor of Diseases of the Nervous System, College of Physicians and Surgeons, 
Baltimore ; Visiting Physician to the City Hospital ; Consulting Neurologist to Bay 
View Asylum and the Hebrew Hospital ; Member American Neurological Associa- 
tion, etc. Illustrated. i2mo. Cloth, $2.00 

Pritchard. Handbook of Diseases of the Ear. 

By Urban Pritchard, m.d., f.r.c.s., Professor of Aural Surgery, King's College, 
London; Aural Surgeon to King's College Hospital; Senior Surgeon to the Royal 
Ear Hospital, etc. Third Edition. Many Illustrations and Formulae. Cloth, $1.50 

Proctor's Practical Pharmacy. 

Lectures on Practical Pharmacy. By Barnard S. Proctor. Third Edition, Re- 
vised. With Elaborate Tables of Chemical Solubilities, etc. Illustrated. Cloth, $3.00 

Reese's Medical Jurisprudence and Toxicology. 

A Text-Book for Medical and Legal Practitioners and Students. By John J. Reese, 
m.d., Editor of "Taylor's Jurisprudence," formerly Professor of the Principles and 
Practice of Medical Jurisprudence, including Toxicology, in the University of Pennsyl- 
vania Medical Department. Fifth Edition, Revised and Edited by Henry Leffmann, 
m.d., Pathological Chemist, Jefferson Medical College Hospital ; Chemist, State Board 
of Health ; Professor of Chemistry, Woman's Medical College of Pennsylvania, etc. 
i2mo. 645 pages. Cloth, $3.00; Leather, $3.50 

"To the student of medical jurisprudence and toxicology it is invaluable, as it is concise, 
clear, and thorough in every respect." — The American Journal of the Medical Sciences. 

Reeves. Medical Microscopy. 

Including Chapters on Bacteriology, Neoplasms, Urinary Examination, etc. By 
James E. Reeves, m.d., ex-President American Public Health Association, etc. 
Numerous Illustrations, some of which are printed in Colors. i2mo. Cloth, $2.50 

Regis. Mental Medicine. 

A Practical Manual. By Dr. E. Regis, formerly Chief of Clinique of Mental Dis- 
eases, Faculty of Medicine of Paris. Authorized Translation by H. M. Bannister, 
m.d., late Senior Assistant Physician, Illinois Eastern Hospital for the Insane, etc. 
With an Introduction by the Author. i2mo. Cloth, 52.00 

Richardson. Long Life 
and How to Reach It. By J. G. Richardson, formerly Professor of Hygiene, Uni- 
versity of Pennsylvania. Cloth, .40 

Rockwood. Chemical Analysis. 

Introduction to Chemical Analysis for Students of Medicine, Pharmacy, and Dentistry. 
By Elbert W. Rockwood, b.s., m.d., Professor of Chemistry, Toxicology, and 
Metallurgy in the Colleges of Medicine, Dentistry, and Pharmacy, University of Iowa, 
Iowa City. Illustrated. Cloth, $1.50 



MEDICAL AND SCIENTIFIC PUBLICATIONS. 



Richardson's Mechanical Dentistry. 
A Practical Treatise on Mechanical Dentistry. By Joseph Richardson, d.d.s. 
Seventh Edition, Thoroughly Revised and in many parts Rewritten by Geo. W. 
Warren, a.m., d.d.s., Professor of Clinical Dentistry and Oral Surgery; Chief of 
the Clinical Staff, Pennsylvania College of Dental Surgery, Philadelphia. With 691 
Illustrations. Octavo. 675 pages. Cloth, $5.00 ; Leather, $6.co 

Richter's Inorganic Chemistry. 
A Text-Book for Students. By Prof. Victor von Richter, University of Breslau. 
Fifth American from Tenth German Edition by Prof. H. K linger, University of 
Konigsberg. Authorized Translation by Edgar F. Smith, m.a., ph.d., Sc.d., 
Professor of Chemistry, University of Pennsylvania ; Member of the Chemical Society 
of Berlin, etc. With many Illustrations and a Colored Plate. i2mo. Cloth, 51.75 

Organic Chemistry. 

The Chemistry of the Carbon Compounds. Third American Edition, Translated 
from Prof. Anschutz's Eighth German Edition by Edgar F. Smith, m.a., 
ph.d., Sc.d., Professor of Chemistry, University of Pennsylvania. Revised 
and Enlarged. Illustrated. i2mo. Two volumes. 

Vol. I. Aliphatic Series. 625 pages. Cloth, $3.00 

Vol. II. Carbocyclic and Heterocyclic Series. 671 pages. Cloth, $3.00 

Roberts. Gynecological Pathology. 

Gynecological Pathology. By Charles Hurbert Roberts, m.d., f.r.c.s., m.r.c.p., 
Physician Queen Charlotte's Lying-in Hospital and to the Samaritan Hospital for 
Women ; Demonstrator of Practical Midwifery and Diseases of Women, and House 
Surgeon St. Bartholomew's Hospital, London. Elaborately Illustrated with 
127 Full-Page Plates containing 151 Figures, several being printed in Colors. 
Octavo. Extra Cloth, Gilt Top, $6.00 

"This very attractive volume will be appreciated by all who teach gynecology or who deal 
practically with diseases of the female reproductive organs." — Edinburgh Medical Journal. 

" This is. a splendid volume, worthy the careful study of every phy^cian who seeks to under- 
stand the diseased conditions he so often meets with in his female patients." — Annals of Gynecology 
and Pediatry. 

Robinson. Latin Grammar of Pharmacy and Medicine. 

By D. H. Robinson, ph.d., Professor of Latin Language and Literature, University 
of Kansas. Introduction by L. E. Sayre, ph.g., Professor of Pharmacy and 
Dean of the Department of Pharmacy in University of Kansas. Third Edition, 
Revised with the help of Prof. L. E. Sayre, of University of Kansas, and Dr. 
Charles Rice, of the College of Pharmacy of the City of New York. Cloth, $1.75 
" This method of preparing medical students and pharmacists for a practical use of the lan- 
guage is in every way to be commended. . . . Pharmacists should know enough to read pre- 
scriptions readily and understandingly." — Johns Hopkins Hospital Bulletin. 

Rosenau. Disinfection and Disinfectants. 

A Practical Guide for Sanitarians, Health and Quarantine Officers. By M. J. Rose- 
nau, m.d., Director of the Hygienic Laboratory and Passed Assistant Surgeon, U. S. 
Marine Hospital Service, Washington, D. C. Illustrated. Just Ready. Cloth, 52.00 

Sayre. Organic Materia Medica and Pharmacognosy. 

An Introduction to the Study of the Vegetable Kingdom and the Vegetable and 
Animal Drugs. Comprising the Botanical and Physical Characteristics, Source, 
Constituents, Pharmacopoeial Preparations ; Insects Injurious to Drugs, and Phar- 
macal Botany. By L. E. Sayre, b.s., ph.m., Dean of the School of Pharmacy and 
Professor of Materia Medica and Pharmacy in the University of Kansas ; Member 
Committee of Revision of the United States Pharmacopoeia, etc. With Sections on 
Histology and Microtechnique by William C. Stevens, Professor of Botany in the 
University of Kansas. Second Edition, Revised and Enlarged. With 374 Illustra- 
tions, the majority of which are from Original Drawings. 8vo. Cloth, $4.50 



34 P. BLAKISTON'S SON &* CO: S 

Schamberg. Compend of Diseases of the Skin. 

By Jay F. Schamberg, Professor of Diseases of the Skin, Philadelphia Polyclinic ; 
Fellow of the College of Physicians of Philadelphia ; Quiz-Master at University of 
Pennsylvania. Second Edition, Revised and Enlarged. 105 Illustrations, f Quiz- 
Compend? Series, No. 16. Cloth, .80; Interleaved, $1.00 

Schofield. The Force of Mind, 

or The Mental Factor in Medicine. By A. T. Schofield, m.d., m.r.c.s. Just 
Ready. Cloth, $2.00 

Schreiner. Diet List. 

Arranged in the Form of a Chart on which Articles of Diet can be Indicated for any 
Disease. By E. R. Schreiner, m.d., Assistant Demonstrator of Physiology, Uni- 
versity of Pennsylvania. Put up in Pads of 50 with Pamphlet of Specimen Dietaries. 

Per Pad, .75 

Scott. The Urine : Its Chemical and Microscopical Examination. 

By Lindley Marcroft Scott, m.a., m.d., etc. With 41 Colored Plates and other 
Illustrations. Quarto. Cloth, #5.00 

Scoville. The Art of Compounding. Second Edition. 

A Text-Book for Students and a Reference Book for Pharmacists. By Wilbur L. 
Scoville, ph.g., Professor of Applied Pharmacy and Director of the Pharmaceutical 
Laboratory in the Massachusetts College of Pharmacy. Second Edition, Enlarged 
and Improved. Cloth, $2.50; Sheep, $3.50; Half Russia, $4.50 

Self-Examination for Medical Students. 

3500 Questions on Medical Subjects, with the proper References to Standard Books 
in which replies may be found, and including Complete Sets of Questions from two 
recent State Board Examinations of Pennsylvania, Illinois, and New York. 641110. 

Paper, 10 cents. 

Smith. Abdominal Surgery. Sixth Edition. 

Being a Systematic Description of all the Principal Operations. By J. Greig Smith, 
m.a., f.r.s.e., Surgeon to British Royal Infirmary. 224 Illustrations. Sixth Edition, 
Enlarged and Thoroughly Revised by James Swain, m.d. (Lond.), f.r.c.s., Pro- 
fessor of Surgery, University College, Bristol, etc. Two vols. 8vo. Cloth, $10.00 

Smith. Electro-Chemical Analysis. 

By Edgar F. Smith, m.a., ph.d., Scd., Professor of Chemistry, University of 
Pennsylvania. Second Edition, Revised and Enlarged. 27 Illustrations. i2mo. 

Cloth, $1.25 
*#* This book has been translated and published in both Germany and France. 

Smith and Keller. Experiments. 

Arranged for Students in General Chemistry. By Edgar F. Smith, m.a., ph.d., 
Sc.d., Professor of Chemistry, University of Pennsylvania, and Dr. H. F. Keller, 
Professor of Chemistry, Philadelphia High School. Fourth Revised Edition. 8vo. 
Illustrated. Cloth, .60 

Smith. Dental Metallurgy. 

A Manual. By Ernest A. Smith, f.c.s., Assistant Instructor in Metallurgy, Royal 
College of Science, London. Illustrated. Second Edition. In Press. 

Smith. Wasting Diseases of Infants and Children. 

By Eustace Smith, m.d., f.r.c.p., Physician to the East London Hospital for 
Children, etc. Sixth Edition, Revised. Cloth, $2.00 



MEDICAL AND SCIENTIFIC PUBLICATIONS. 35 

Starling. Elements of Human Physiology. 

By Ernest H. Starling, m.d. (Lond.), m.r.c.p., Joint Lecturer on Physiology at 
Guy's Hospital, London, etc. With ioo Illus. i2mo. 437 pages. Cloth, $1.00 

Starr. The Digestive Organs in Childhood. 

The Diseases of the Digestive Organs in Infancy and Childhood. By Louis Starr, 
m.d., late Clinical Professor of Diseases of Children in the Hospital of the University 
of Pennsylvania; Physician to the Children's Hospital, Philadelphia. Third 
Edition, Revised and Enlarged. Illustrated. Octavo. Just Ready. Cloth, $3.00 

The Hygiene of the Nursery. 

Including the General Regimen and Feeding of Infants and Children, and the 
Domestic Management of the Ordinary Emergencies of Early Life, Massage, etc. 
Sixth Edition, Enlarged. 25 Illustrations. i2mo. Cloth, $1.00 

*x* General and specific rules for feeding are given, and Diet Lists from the first 
week up to the eighteenth month, with various recipes for artificial foods, peptonized 
milk, etc. Directions for the sterilization of milk, substitutes for milk, preparation of 
food for both well and siak children, nutritious enemata, etc., and the general manage- 
ment of the Nursery. 

Stearns. Lectures on Mental Diseases. 

By Henry Putnam Stearns, m.d., Physician-Superintendent at the Hartford Retreat ; 
Lecturer on Mental Diseases in Yale University. With a Digest of Laws of the 
Various States Relating to Care of Insane. Illustrated. Cloth, $2.75 ; Sheep, $3.25 

Steell. The Physical Signs of Pulmonary Disease. 

By Graham Steel, m.d., f.r.c.p., Physician to the Manchester Royal Infirmarj' ; 
Lecturer on Clinical Medicine and on Diseases of the Heart at Owens College. 
Illustrated. Cloth, $1.25 

Stevenson and Murphy. A Treatise on Hygiene. 

By Various Authors. Edited by Thomas Stevenson, m.d., f.r.c.p., Lecturer on 
Chemistry and Medical Jurisprudence at Guy's Hospital, London, and Shirley F. 
Murphy, Medical Officer of Health to the County of London. In three octavo 
volumes. 

Vol. I. With Plates and Wood Engravings. Octavo. Cloth, $6.00 

Vol. II. With Plates and Wood Engravings. Octavo. Cloth, $6.00 

Vol. III. Sanitary Law. Octavo. Cloth, $5.00 

*%* Special Circular upon application. 

Stewart's Compend of Pharmacy. 

Based upon "Remington's Text-Book of Pharmacy." By F. E. Stewart, m.d., 
ph.g., late Quiz-Master in Chemistry and Theoretical Pharmacy, Philadelphia College 
of Pharmacy ; Lecturer on Pharmacology, Jefferson Medical College. Fifth Edition. 
Complete Tables of Metric and English Weights and Measures. ? Quiz -Co?np end ? 
Series. Cloth, .80 ; Interleaved for the Addition of Notes, $1.00 

Stirling. Outlines of Practical Physiology. 

Including Chemical and Experimental Physiology, with Special Reference to Practical 
Medicine. By W. Stirling, m.d., scd., Professor of Physiology and Histology, 
Owens College, Victoria University, Manchester ; Examiner in Physiology, Univer- 
sities of Edinburgh and London. Third Edition. 289 Illustrations. Cloth, $2.00 

Outlines of Practical Histology. 

368 Illustrations. Second Edition, Revised and Enlarged. With new Illustra- 
tions. i2mo. Cloth, $2.00 



P. BLAKISTON'S SON &* CO: S 



Stohr. Text-Book of Histology, Including the Microscopical 
Technic. 379 Illustrations. New Edition. 
By Dr. Philip Stohr, Professor of Anatomy at University of Wiirzburg. Author- 
ized Translation by Emma L. Bilstein, m.d., formerly Demonstrator of Histology, 
Woman's Medical College of Penna. Edited, with Additions, by Dr. Alfred 
Schaper, Professor of Anatomy, University of Breslau; formerly Demonstrator of 
Histology, Harvard Medical School, Boston. Fourth American based upon the Ninth 
German Edition, Enlarged and Revised. 379 Illustrations. Octavo. Cloth, $3.00 
"This edition of an already well-known student's manual requires little but favorable com- 
ment. Its other editions have made it well and favorably known, and this one only makes the 
work's position more secure. The book is not only a useful one for the student, but makes a very 
good work of reference for its subject, and is thus entitled to a place upon the shelves of the prac- 
titioner." — The Medical Record, New York. 

Sturgis. Manual of Venereal Diseases. Seventh Edition. 

By F. R. Sturgis, m.d., Sometime Clinical Professor of Venereal Diseases in the 
Medical Department of the University of the City of New York ; formerly one of 
the Visiting Surgeons to Charity Hospital, Blackwells Island, Department of Vene- 
real Diseases ; Member of the American Association of Gen* to -Urinary Surgeons, etc. 
Seventh Edition, Revised and in part Rewritten by F. R. Sturgis, m.d., and Follen 
Cabot, m.d., Instructor in Genito-Urinary and Venereal Diseases in the Cornell Uni- 
versity Medical College ; Genito-Urinary Out-Patient Surgeon to Bellevue Hospital ; 
Visiting Dermatologist to the New York City (Charity) Hospital ; Lecturer on Genito- 
Urinary and Venereal Diseases, University of Vermont, 1900. i2mo. 200 pages. 

Cloth, $1.25 

Sutton's Volumetric Analysis. 

A Systematic Handbook for the Quantitative Estimation of Chemical Substances by 
Measure, Applied to Liquids, Solids, and Gases. Adapted to the Requirements of 
Pure Chemical Research, Pathological Chemistry, Pharmacy, Metallurgy, Photog- 
raphy, etc., and for the Valuation of Substances Used in Commerce, Agriculture, 
and the Arts. By Francis Sutton, f.c.s. Eighth Edition, Revised and Enlarged. 
With 116 Illustrations. 8vo. Cloth, $5.00 

Swanzy. Diseases of the Eye and their Treatment. 

A Handbook for Physicians and Students. By Henry R. Swanzy, a.m., m.b., 
f.r.c.S.i., Examiner in Ophthalmology, University of Dublin ; Surgeon to the National 
Eye and Ear Infirmary ; Ophthalmic Surgeon to the Adelaide Hospital, Dublin. 
Seventh Edition, Thoroughly Revised and Enlarged. 165 Illustrations, one Plain 
Plate, and a Zephyr Test Card. i2mo. . Cloth, $2.50 

" Is without doubt the most satisfactory manual we have upon diseases of the eye. It occu- 
pies the middle ground between the students' manuals, which are too brief and concise, and the 
encyclopedic treatises, which are too extended and detailed to be of special use to the general 
practitioner." — Chicago Medical Recorder. 

Symonds. Manual of Chemistry 

for Medical Students. By Brandreth Symonds, a.m., m.d., Assistant Physician 
Roosevelt Hospital, Out-Patient Department, New York. Second Edition. i2mo. 

Cloth, $2.00 

Taft. Index of Dental Periodical Literature. 

By Jonathan Taft, d.d.s. 8vo. Cloth, $2.00 

Tanner's Memoranda of Poisons 

and their Antidotes and Tests. By Thos. Hawkes Tanner, m.d. Eighth Edition, 
Revised by Henry Leffmann, m.d., Professor of Chemistry, Woman's Medical Col- 
lege of Penna.; Vice-President Society of Public Analysts. i2mo. Cloth, .75, 



MEDICAL AND SCIENTIFIC PUBLICATIONS. 37 

Tavera. Medicinal Plants of the Philippines. 

By T. H. Pardo de Tavera, Doctor of Medicine in Faculty of Paris ; Scientific 
Commissioner S.M. in Philippine Islands, etc. Translated and Revised by Jerome 
B. Thomas, Jr., a.b., m.d., Captain and Assistant Surgeon United States Volunteers. 

Cloth, $2.00 

Taylor. Practice of Medicine. 

By Frederick Taylor, m.d., Physician to, and Lecturer on Medicine at, Guy's 
Hospital, London ; Physician to Evelina Hospital for Sick Children. Sixth Edition, 
Revised. Cloth, $4.00 

Taylor and Wells. Diseases of Children. Illustrated. 

A Manual for Students and Physicians. By John Madison Taylor, a.m., m.d.. 
Professor of Diseases of Children, Philadelphia Polyclinic ; Pediatrist to the Philadel- 
phia Hospital ; Assistant Physician to the Children's Hospital ; Consulting Physician 
to the Elwyn and the Vineland Training Schools for Feeble-minded Children ; 
Neurologist to the Howard Hospital, etc.; and William H. Wells, m.d., Adjunct 
Professor of Obstetrics and Diseases of Infancy in the Philadelphia Polyclinic ; 
Demonstrator of Clinical Obstetrics, Jefferson Medical College ; Chief Gynecologist, 
Mt. Sinai Hospital. With Numerous Illustrations. Second Edition, Revised and 
Enlarged. Octavo. Cloth, $4.50 

Temperature Charts 

for Recording Temperature, Respiration, Pulse, Day of Disease, Date, Age, Sex, 
Occupation, Name, etc. Put up in pads ; each .50 

Thayer. Compend of General Pathology. 

Specially adapted for Medical Students and Physicians. By A. E. Thayer, m.d., 
Assistant Instructor in Pathology, Cornell Medical School ; Pathologist to the City- 
Hospital, New York City, etc. 78 Illustrations. No. ij ? Quiz- Compend ? Series. 
i2mo. Just Ready. Cloth, .80; Interleaved for Notes, $1.00 

Compend of Special Pathology. 34 Illustrations. 

No. 18 ? Quiz- Compend? Series. Just Ready. Cloth, .80; Interleaved, $1.00 

Thorington. Retinoscopy. Fourth Edition. 

(The Shadow Test) in the Determination of Refraction at One Meter Distance with 
the Plane Mirror. By James Thorington, a.m., m.d., Professor of Diseases of the 
Eye in the Philadelphia Polyclinic ; Ophthalmologist to the Elwyn, Vineland, and 
New Jersey State Training Schools for Feeble-minded Children ; Lecturer on the 
Anatomy, Physiology, and Care of the Eyes in the Philadelphia Manual Training 
Schools, etc. 51 Illustrations, several of which are Colored. Fourth Edition, En- 
larged. i2mo. Cloth, $1.00 

Refraction and How to Refract. Second Edition. 

With 200 Illustrations, most of which, are made from Original Drawings, and 
13 of which are in Colors. Second Edition, Revised. i2mo. Cloth, $1.50 

Synopsis of Contents. — I. Optics. II. The Eye ; The Standard Eye ; 
Cardinal Points ; Visual Angle ; Minimum Visual Angle ; Standard Acuteness of 
Vision ; Size of Retinal Image, Accommodation ; Mechanism of Accommoda- 
tion ; Far and Near Point ; Determination of Distant Vision and Near Point ; 
Amplitude of Accommodation ; Convergence ; Angle Gamma ; Angle Alpha. 
III. Ophthalmoscope ; Direct and Indirect Method. IV. Emmetropia ; Hyper- 
opia ; Myopia. V. Astigmatism or Curvature Ametropia ; Tests for Astigma- 
tism. VI. Retinoscopy. VII. Muscles. VIII. Cycloplegics ; Cycloplegia ; 
Asthenopia ; Examination of the Eyes. IX. How to Refract. X. Applied 
Refraction. XI. Presbyopia ; Aphakia ; Anisometropia ; Spectacles. XII. 
Lenses ; Spectacle and Eye Glass Frames ; How to Take Measurements for 
Them and How They Should be Fitted. Index. 



P. BLAKISTON'S SON &- CO.'S 



Thorne. The Schott Methods of the Treatment of Chronic Dis- 
eases of the Heart. 

With an Account of the Nauheim Baths and of the Therapeutic Exercises. By W. 
Bezly Thorne, m.d., m.r.c.p. With Plates and Numerous other Illustrations. 
Fourth Edition, Revised and Enlarged. Octavo. Just Ready. Cloth, $2.00 

Thresh. Water and Water Supplies. 

By John C. Thresh, d.sc. (Lond.), m.d., d.p.h. (Cambridge), Medical Officer of 
Health to the Essex County Council ; Lecturer on Public Health, King's College, 
London ; Fellow of the Institute of Chemistry ; Member Society Public Analysts, 
etc. Third Edition, Revised and very much Enlarged. Illustrated. 527 pages. 
i2mo. Cloth, $2.00 

Tissier. Pneumatotherapy and Inhalation Methods. 
See Cohen, Physiologic Therapeutics, page 10. 

Tomes' Dental Anatomy. 

A Manual of Dental Anatomy, Human and Comparative. By C. S. Tomes, d.d.s. 
263 Illustrations. Fifth Edition. i2mo. Cloth, $4.00 

Dental Surgery. 

A System of Dental Surgery. By John Tomes, f.r.s. Fourth Edition, Thor- 
oughly Revised by C. S. Tomes, d.d.s. With 289 Illustrations. i2mo. 717 
pages. Cloth, $4.00 

Traube. Physico-Chemical Methods. 

By Dr. J. Traube, Privatdocent in the Technical High School of Berlin. Author- 
ized Translation by W. D. Hardin, Harrison Senior Fellow in Chemistry, University 
of Pennsylvania. With 97 Illustrations. 8vo. Cloth, $1.50 

Treves. German-English Medical Dictionary. 
By Frederick Treves, f.r.c.s., assisted by Dr. Hugo Lang, b.a. (Munich). 
i2mo. Half Calf, $3.25 

Physical Education : Its Effects, Value, Methods, etc. 8vo. 

Cloth, .75 
Tuke. Dictionary of Psychological Medicine. 

Giving the Definition, Etymology, and Synonyms of the Terms used in Medical Psy- 
chology, with the Symptoms, Pathology, and Treatment of the Recognized Forms of 
Mental Disorders, together with the Law of Lunacy in Great Britain and Ireland. 
Edited by D. Hack Tuke, m.d., ll.d., Examiner in Mental Physiology in the Uni- 
versity of London. Two volumes. Octavo. Cloth, $10.00 
" A comprehensive, standard book." — The British Medical Journal. 

" It is vastly more than a Dictionary. It is an elaborate and complete Encyclopaedia of 
Psychological Medicine ; in fact, a small library in itself on that subject. The high expectations 
which Dr. Tuke's work in this field had raised are more than fulfilled. ... It will be found 
to be a most useful reference handbook for the alienist and student. The general physician also 
cannot fail to find the book exceedingly useful in special cases." — Boston Medical and Surgical 
Journal. 

"We believe that the student might obtain a better knowledge of insanity from this work than 
from most of the text-books, besides a great deal of interesting and valuable information nowhere 
else accessible." — American Journal of Insanity. 

Turnbull's Artificial Anesthesia. 

A Manual of Anesthetic Agents in the Treatment of Diseases, also their Employment 
in Dental Surgery ; Modes of Administration ; Considering their Relative Risks ; 
Tests of Purity ; Treatment of Asphyxia ; Spasms of the Glottis ; Syncope, etc. By 
Laurence Turnbull, m.d., ph.g., Aural Surgeon to Jefferson College Hospital, etc. 
Fourth Edition, Revised. 54 Illustrations. i2mo. Cloth, $2.50 



MEDICAL AND SCIENTIFIC PUBLICATIONS. 39 

Tyson. The Practice of Medicine. Second Edition. 

A Text-Book for Physicians and Students, with Special Reference to Diagnosis and 
Treatment. By James Tyson, m.d., Professor of Medicine in the University of 
Pennsylvania; Physician to the University and to the Philadelphia Hospitals, etc. 
With Colored Plates and many other Illustrations. Second Edition, Revised and 
Enlarged. 127 Illustrations. 8vo. 1222 pages. 

Cloth, $5.50; Leather, $6.50; Half Russia, $7.50 

*#* This edition has been entirely reset from new type. The author has revised it 
carefully and thoroughly, and added much new material and 37 new illustrations. 

" This work not only represents the work of a practitioner of great experience, but of a care- 
ful culling of the facts set forth in contemporary literature by one who well understands the art of 
separating the true from the false." — The Jottrnal of the American Medical Association, Chicago. 

" Represents the outcome of much well-directed labor, and constitutes a reliable and useful 
text-book." — The London Lancet. 

" Few teachers in the country can claim a longer apprenticeship in" the laboratory and at the 
bedside, none a more intimate acquaintance with students, since in one capacity or another he has 
been associated with the University of Pennsylvania and the Philadelphia Hospital for nearly thirty 
years. Moreover, he entered medicine through the portal of pathology, a decided advantage in 
the writer of a text-book. . . . The typography is decidedly above works of this class issued 
from our publishing houses. There is no American Practice of the same attractive appearance. 
The print is unusually sharp and clear, and the quality of the paper particularly good. ... It 
is a piece of good, honest work, carefully conceived and conscientiously carried out." — University 
Medical Magazine. 

*£* Sample Pages and Illustrations sent free upon application. 

Guide to the Examination of Urine. 

For the Use of Physicians and Students. With Colored Plate and Numerous 
Illustrations Engraved on W T ood. Tenth Edition, Revised, Enlarged and partly 
Rewritten. i2mo. Just Ready . Cloth, $1.50 

" The book is a reliable one and has no superior among the numerous manuals devoted to the 
subject." — Boston Medical and Surgical Journal. 

" No similar treatise has been so long before the professional public, and none comes so near 
to being a classic on the subject of which it treats as does this one." — Buffalo Medical Journal. 

Handbook of Physical Diagnosis. 

Fourth Edition, Revised and Enlarged. With two Colored Plates and 55 other 
Illustrations. 298 pages. i2mo. Cloth, $1.50 

Cell Doctrine. 

Its History and Present State. Second Edition. Cloth, $1.50 

United States Pharmacopoeia, 1890. 

Seventh Decennial Revision. Cloth, $2.50 (Postpaid, $2.77); Sheep, $3.00 (Post- 
paid, $3.27); Interleaved, $4.00 (Postpaid, $4.50). Printed on one side of page 
only, unbound, $3.50 (Postpaid, $3.90). 

Select Tables from the U. S. P. 

Being Nine of the Most Important and Useful Tables, printed on Separate 
Sheets. Carefully put up in Patent Envelope. .25 



40 P. BLAKISTON'S SON &- CO. 1 S 

Ulzer and Fraenkel. Introduction to Chemical-Technical Analysis. 
By Prof. F. Ulzer and Dr. A. Fraenkel, Directors of the Testing Laboratory of 
the Royal Technological Museum, Vienna. Authorized Translation by Hermann 
Fleck, nat.sc.d., Instructor in Chemistry and Chemical Technical Analysis in the 
John Harrison Laboratory of Chemistry, University of Pennsylvania, with an 
Appendix by the Translator relating to Food Stuffs, Asphaltum, and Paint. 12 Illus- 
trations. 8vo. Cloth, $1.25 

Van Niiys on the Urine. 

Chemical Analysis of Healthy and Diseased Urine, Qualitative and Quantitative. By 
T. C. Van Nuys. 39 Illustrations. Octavo. Cloth, $1.00 

Van Harlingen on Skin Diseases. 

A Practical Manual of Diagnosis and Treatment, with Special Reference to Differential 
Diagnosis. By Arthur Van Harlingen, m.d., Emeritus Professor of Diseases of 
the Skin in the Philadelphia Polyclinic ; Dermatologist to the Children's Hospital. 
Third Edition, Revised and Enlarged. With Formulae and Illustrations, several being 
in Colors. 580 pages. Cloth, $2.75 

" As would naturally be expected from the author, his views are sound, his information 

extensive, and in matters of practical detail the hand of the experienced physician is everywhere 

visible." — The Medical News. 

Virchow's Post-mortem Examinations. 

A Description and Explanation of the Method of Performing them in the Dead- 
House of the Berlin Charite Hospital, with Especial Reference to Medico-Legal 
Practice. By Professor Virchow. Translated by Dr. T. P. Smith. Illustrated. 
Third Edition. Cloth, .75 

Voswinkel. Surgical Nursing. 

A Manual for Nurses. By Bertha M. Voswinkel, Graduate Episcopal Hospital, 
Philadelphia; late Nurse-in-Charge Children's Hospital, Columbus, O. Second 
Edition, Revised and Enlarged. 1 1 1 Illustrations. i2mo. Cloth, $1.00 

Walker. Students' Aid in Ophthalmology. 

By Gertrude A. Walker, a.b., m.d., Clinical Instructor in Diseases of the Eye at 
Woman's Medical College of Pennsylvania. 40 Illustrations and Colored Plate. 
i2mo. Cloth, $1.50 

Walsham. Surgery : Its Theory and Practice. Seventh Edition. 

For Students and Physicians. By Wm. J. Walsham, m.d., f.r.c.s., Senior Assist- 
ant Surgeon to, and Demonstrator of Practical Surgery in, St. Bartholomew's Hospital ; 
Surgeon to Metropolitan Free Hospital, London. Seventh Edition, Revised and En- 
larged by 100 pages. With 483 Illustrations and 28 Skiagrams. Cloth, $3.50 

Warren. Compend of Dental Pathology and Dental Medicine. 
Containing all the most Noteworthy Points of Interest to the Dental Student and a 
Chapter on Emergencies. By George W. Warren, d.d.s., Professor of Clinical 
Dentistry and Oral Surgery ; Clinical Chief, Pennsylvania College of Dental Surgery, 
Philadelphia. Third Edition, Enlarged. Illustrated. Being No. ij ? Quiz- Com- 
pend f Series. i2mo. Cloth, .80 ; Interleaved for the Addition of Notes, #1.00 

Dental Prosthesis and Metallurgy. 

129 Illustrations. Cloth, $1.25 

Weber and Hinsdale. Climatology — Health Resorts — Mineral 
Springs. 
See Cohen, Physiologic Therapeutics, page 10. 



MEDICAL AND SCIENTIFIC PUBLICATIONS. 41 

Wells. Compend of Gynecology. 

By Wm. H. Wells, m.d., Demonstrator of Clinical Obstetrics, Jefferson Medical 
College, Philadelphia ; Chief Gynecologist Mt. Sinai Hospital ; Fellow of the College 
of Physicians of Philadelphia. Second Edition, Revised. 140 Illustrations. Being 
No. 7 ? Quiz- Compend? Series. i2mo. Cloth, .80; Interleaved for Notes, $1.00 

Wethered. Medical Microscopy. 

A Guide to the Use of the Microscope in Practical Medicine. By Frank J. Weth- 
ered, m.d., m.r.c.p., Demonstrator of Practical Medicine, Middlesex Hospital Med- 
ical School ; Assistant Physician, late Pathologist, City of London Hospital for 
Diseases of the Chest, etc. With a Colored Plate and 101 Illustrations. 406 pages. 
i2mo. Cloth, $2.00 

Weyl. Sanitary Relations of the Coal-Tar Colors. 

By Theodore Weyl. Authorized Translation by Henry Leffmann, m.d., ph.d 
i2mo. Cloth, $1.25 

Whitacre. Laboratory Text-Book of Pathology. 

By Horace J. Whitacre, m.d., Demonstrator of Pathology, Medical College of 
Ohio, Cincinnati. Illustrated with 121 Original Drawings and Microphotographs. 
8vo. Cloth, $1.50 

White. The Mouth and Teeth. Illustrated. 

By J. W. White, m.d., d.d.s. Cloth, .40 

White and Wilcox. Materia Medica, Pharmacy, Pharmacology, and 

Therapeutics. Fifth Edition. 

A Handbook for Students. By W. Hale White, m.d., f.r.c.p., etc., Physician to, 
and Lecturer on Materia Medica and Therapeutics, Guy's Hospital ; Examiner in 
Materia Medica to the Conjoint Board, etc. Fifth American Edition, Revised by 
Reynold W. Wilcox, m.a., m.d., ll.d., Professor of Clinical Medicine and Thera- 
peutics at the New York Post-Graduate Medical School and Hospital ; Visiting Phy- 
sician, St. Mark's Hospital ; Assistant Visiting Physician, Bellevue Hospital. En- 
larged and Improved. i2mo. Cloth, $3.00; Leather, $3.50 

Williams. Manual of Bacteriology. Second Edition. 

By Herbert U. Williams, m.d., Professor of Pathology and Bacteriology, Medical 
Department, University of Buffalo. Second Edition, Revised and Enlarged. 90 
Illustrations. i2mo. 290 pages. Cloth, $1.50 

Wilson. Handbook of Hygiene and Sanitary Science. 

By George Wilson, m.a., m.d., f.r.s.e., Medical Officer of Health for Mid-War- 
wickshire* England. With Illustrations. Eighth Edition. i2mo. Cloth, $3.00 

Wilson. The Summer and its Diseases. 

By James C. Wilson, m.d., Professor of the Practice of Medicine and Clinical 
Medicine, Jefferson Medical College, Philadelphia. Cloth, .40 

Wilson. System of Human Anatomy. 

Eleventh Revised Edition, Edited by Henry Edward Clark, m.d., m.r.c.s. 492 
Illustrations, 26 Colored Plates, and a Glossary of Terms. i2mo. Cloth, #5.00 

Winckel. Text-Book of Obstetrics. 

Including the Pathology and Therapeutics of the Puerperal State. By Dr. F. 
Winckel, Professor of Gynecology, Royal University Clinic for Women in Munich. 
Authorized Translation by J. Clifton Edgar, a.m., m.d., Professor of Obstetrics 
and Clinical Midwifery, Cornell University Medical Department, New York. 190 
Illustrations. Octavo. Cloth, $5.00 ; Leather, $6.00 



42 



P. BLAKISTON'S SON &* CO.' S PUBLICATIONS. 



Winternitz. Hydrotherapy — Thermotherapy — Balneology. 
See Cohen, Physiologic Therapeutics, page 10. 

Wood. Brain Work and Overwork. 

By H. C. Wood, Clinical Professor of Nervous Diseases, University of Pennsylvania. 
i2mo. Cloth, .40 

Woody. Essentials of Medical and Clinical Chemistry. 

With Laboratory Exercises. By Samuel E. Woody, a.m., m.d., Professor of Chem- 
istry and Diseases of Children in the Medical Department, Kentucky University, 
Louisville. Fourth Edition, Revised and Enlarged. Illustrated. i2mo. Cloth, $1.50 

" The fact that Prof. Woody's little book has reached a third edition in such a short time is 
sufficient proof of its usefulness for, and demand by, the medical student. The selection of the 
material and its plan of presentation, resulting from the author's large experience as a practitioner 
and teacher of medical chemistry, is well intended to offer to the student that which is really essen- 
tial for his limited college course, and, it is to be hoped, a basis for further instruction in the impor- 
tant branch of medical science." — The American Journal of Medical Sciences, Philadelphia. 

Wright. Ophthalmology. New Edition. 1 17 Illustrations. 

A Text-Book by John W. Wright, a.m., m.d., Professor of Ophthalmology and 
Clinical Ophthalmology in Ohio Medical University ; Ophthalmologist to the Protest- 
ant and University Hospitals, etc. Second Edition, Revised, Rewritten, and Enlarged. 
With many new Illustrations. Cloth, $3.00 



THE STANDARD TEXT=BOOK 



New Edition 



Morris' Anatomy 

Third Revised Edition, Enlarged and Improved 

846 Illustrations, of which 267 are Colored 

Octavo. J328 Pages. Cloth, $6.00; Leather, $7.00 

" Morris' Anatomy" was published at a time when methods of teaching, 
the art of engraving, and distinct advance in anatomical illustration 
made desirable a new and modern text-book. The rapid sale of the first 
edition, its immediate adoption as a text-book by a large number of medi- 
cal schools, and its purchase by physicians and surgeons proved its value 
and made it from the day of publication a standard authority. 

In making this new edition the editors and publishers haVe used every 
endeavor to enhance its value. The text has been thoroughly revised and 
in many parts rewritten ; the editor has devoted himself to the task of 
making it a harmonious whole ; many new illustrations have replaced 
those used in the first edition, and a large number have been printed in 
colors, while the typographical appearance has been improved in several 
particulars. 

The illustrations, in correctness and excellence of execution, are equaled 
by no similar treatise; about $1000 having been expended on new and 
improved blocks for this edition alone. 

" The evergrowing popularity of the book with teachers and students is an index of its value, 
and it may safely be recommended to all interested." — Medical Record, New York. 

" Of all the text-books of moderate size on human anatomy in the English language, Morris 
is undoubtedly the most up-to-date and accurate." — Philadelphia Medical Journal. 

*** CIRCULAR WITH SAMPLE PAGES AND ILLUSTRATIONS FREE. 



THUMB 
INDEX 
IN EACH 
COPY 



From the Southern Clinic. 

" We know of no series of books issued by any house that so fully meets our approval as thes« 
Quiz-Compends ?. They are well arranged, full, and concise, and are really the best line of text- 
books that could be found for either student or practitioner." 



BLAKISTON'S ?QUIZ=COMPENDS? 

The Best Series of Manuals for the Use of Students. 
Price of each, Cloth, .80. Interleaved for taking Notes, Sl.OO. 

Jg^gp^These Compends are based on the most popular text-books and the lectures of prominent 
professors, and are kept constantly revised, so that they may thoroughly represent the present state 
of the subject upon which they treat. The authors have had large experience as Quiz-Masters 
and attaches of colleges, and are well acquainted with the wants of students. They are arranged 
in the most approved form, thorough and concise, containing over 900 illustrations, inserted 
wherever they could be used to advantage. Can be used by students of any college, and contain 
information nowhere else collected in such a condensed practical shape. 

No. 1. HUMAN ANATOMY. Sixth Revised and Enlarged Edition. Including Vis- 
ceral Anatomy. Can be used with either Morris's or Gray's Anatomy. 1 17 Illustrations and 
16 Lithographic Plates of Nerves and Arteries, with Explanatory Tables, etc. By SAMUEL 
O. L. Potter, m.d., formerly Professor of the Practice of Medicine, Cooper Medical College, 
San Francisco ; Major and Brigade Surgeon, U. S. Vol. 

No. 2. PRACTICE OF MEDICINE. Part I. Sixth Edition, Revised, Enlarged, and 
Improved. By Dan'l E. Hughes, M.d., Physician-in-Chief, Philadelphia Hospital; late 
Demonstrator of Clinical Medicine, Jefferson Medical College, Philadelphia. 

No. 3. PRACTICE OF MEDICINE. Part II. Sixth Edition, Revised, Enlarged, and 
Improved. Same author as No. 2. 

No. 4. PHYSIOLOGY. Tenth Edition, with new Illustrations. Enlarged and Revised. 
By A. P. Brubaker, m.d., Professor of Physiology in the Pennsylvania College of Dental 
Surgery; Adjunct Professor of Physiology, Jefferson Medical College, Philadelphia. 

No. 5. OBSTETRICS. Seventh Edition. By Henry G. Landis, m.d. Revised and 
Edited by Wm. H. Wells, m.d., Demonstrator of Clinical Obstetrics, Jefferson Medical 
College, Philadelphia. Enlarged. 52 Illustrations. 

No. 6. MATERIA M E D I C A, THERAPEUTICS, AND PRESCRIPTION 
WRITING. Sixth Revised Edition. Same author as No. 1 . 

No. 7. GYNECOLOGY. Second Edition. By Wm. H. Wells, m.d., Demonstrator of 
Clinical Obstetrics, Jefferson Medical College, Philadelphia. 140 Illustrations. 

No. 8. DISEASES OF THE EYE AND REFRACTION. Second Edition. Includ- 
ing Treatment and Surgery and a Section on Local Therapeutics, By George M. Gould, 
m.d., Editor Philadelphia Medical Journal, and W. L. Pyle, m.d. , Assistant Surgeon, Wills 
Eye Hospital. With Formulae, Glossary, several useful Tables, and 109 Illustrations. 

No. 9. SURGERY, Minor Surgery, and Bandaging. Fifth Edition, Enlarged and Im- 
proved. By Orville Horwitz, b.s., M.d., Clinical Professor of Genito-Urinary Surgery 
and Venereal Diseases in Jefferson Medical College ; Surgeon to Philadelphia Hospital, etc. 
With 98 Formulae and 167 Illustrations. 

No. 10. MEDICAL CHEMISTRY. Fourth Edition. Including Urinalysis, Chemistry of 
Milk, Blood, etc. By Henry Leffmann, m.d., Professor of Chemistry in Pennsylvania 
College of Dental Surgery and in the Woman's Medical College, Philadelphia. 

No. 11. PHARMACY. Fifth Edition. Based upon Professor Remington's Text-Book of 
Pharmacy. By F. E. Stewart, m.d., ph.g., late Quiz- Master in Pharmacy and Chemistry, 
Philadelphia College of Pharmacy; Lecturer at Jefferson Medical College. 

No. 12. VETERINARY ANATOMY AND PHYSIOLOGY. Illustrated. By Wm. 
R. Ballou, m.d., Professor of Equine Anatomy at New York College of Veterinary Sur- 
geons ; Physician to Bellevue Dispensary, etc. With 29 graphic Illustrations. 

No. 13. DENTAL PATHOLOGY AND DENTAL MEDICINE. Third Edition, 
Illustrated. By George W. Warren, d.d.s., Pennsylvania College of Dentai Surgery. 

No. 14. DISEASES OF CHILDREN. Colored Plate. By Marcus P. Hatfield, 
Professor of Diseases of Children, Chicago Medical College. Second Edition, Preparing. 

No. 15. GENERAL PATHOLOGY. Illustrated. By A. E. Thayer, m.d., etc. Just Ready. 

No. 16. DISEASES OF THE SXIN. By Jay F. Schamberg, m.d, Professor of Skin 
Diseases, Philadelphia Polyclinic. Second Edition, Revised. 105 Illustrations. 

No. 17. HISTOLOGY. Illustrated. By H. H. Cushing, m.d. Preparing. 

No. 18. SPECIAL PATHOLOGY. Illustrated. By same author as No. 15. Just Ready. 



PRACTICAL GYNECOLOGY 

A Modern Comprehensive Text-Book 
By E. E. MONTGOMERY, M.D. 

Professor of Gynecology, Jefferson Medical College ; Gynecologist to the Jefferson Medical 

College and St. Joseph's Hospitals; Consulting Gynecologist to 

the Philadelphia Lying-in Charity 

WITH FIVE HUNDRED AND TWENTY-SEVEN 
ILLUSTRATIONS 

Nearly all of which have been Drawn and Engraved Specially for this 
"Work, for the most part from Original Sources 

OCTAVO. 819 PAGES. CLOTH, $5.00 ; LEATHER, $6.00 



From THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION 

"Fashion in medical book-making seems to be running to the composite, which 
may be advantageous and the means of producing a better book than one written by 
an individual. It may be the old-fashioned notions of the reviewer, but he belives in 
the old idea of one book, one author, and he should have all the responsibility, all the 
criticism, and all the glory that attach to it. The composite is likely to be written 
under a ' rush ' order — so much space, in so much time, for so much money. The work 
before us is the work of one individual, and the personality of that individual is evident 
through the whole book. . ♦ . The result shows painstaking effort in every detail, 
in conciseness of statements, in arrangement of subjects, and in the systematic order 
and completeness in which each is considered. . . . The author is neither too 
radical nor too conservative in his consideration of the conditions that may need radical 
operations. In the introduction he tells us that the true gynecologist must be ' so con 
servative that he will sacrifice no organ whose physiologic integrity is capable of being 
restored; so bold and courageous that his patient shall not forfeit her opportunity for 
life or restored health through his failure to assume the responsibility of any operative 
procedure necessary to secure the object.' This is the basal idea that permeates the 
book : the ultra-radical operator will find no endorsement, and the 'tinkering* gynecologist— 
he who treats all diseases of women by means of a pledget of cotton and a speculum — 
no encouragement in its pages. 

"The book is one that can be recommended to the student, to the general practi- 
tioner — who must sometimes be a gynecologist to a certain extent whether he will or not 
— and to the specialist, as an ideal and in every way complete work on the gynecology of 
to-day — a practical work for practical workers." 



DESCRIPTIVE CIRCULAR UPON APPLICATION. 

44 



JACOBSON'S 

OPERATIONS OF SURGERY 

The Operations of Surgery. By W. H. A. Jacobson, 
F.R.C.S., Surgeon to Guy's Hospital, Consulting Surgeon 
Royal Hospital for Children and Women, Member Court 
of Examiners Royal College of Surgeons, Joint Editor 
Annals of Surgery ; and F. J. Steward, F.R.C.S., Assistant 
Surgeon Guy's Hospital and to the Hospital for Sick 
Children. Fourth Edition, Revised, Enlarged and Im- 
proved. 550 Illustrations; Two Volumes ; Octavo; 1524 
Pages. Cloth, Si 0.00; Sheep or Half Morocco, $12.00 

This printing has been increased in size over the former edition 
by 200 pages and contains 150 additional illustrations. 

PRESS NOTICES OF FORMER EDITIONS 

' ' Far more than a mere guide to operating, it is essentially a clinical work and in 
that lies one of its conspicuous merits." — The London Lancet. 

"The author proves himself a judicious operator as shown by his choice of 
methods, and by the emphasis with which he refers to the different dangers and com- 
plications which may arise to mar success or jeopardize life." — New York Medical 
Record. 

" Many of the difficulties met with at the time of an operation, and the troubles 
ensuing after an operation, which are only known to the practical surgeon, are brought 
out prominently in this book." — Boston Medical and Surgical Journal. 

1 ' The important anatomical points are clearly set forth,- the conditions indicating or 
contraindicating operative interference are given, the details of the operations them- 
selves are brought forward prominently, and frequently the after-treatment is considered. 
Herein is one of the strong points of the book." — New York Medical Journal. 

%* Jacobson's Operations of Surgery is not intended only for 
those of great surgical experience or skill, but is intended largely as 
an authoritative guide for the General Physician and Hospital 
Resident who, in emergencies where immediate surgical intervention 
is demanded, must act quickly, and often rely solely upon his own 
judgment. 

Comprehensive in scope, exhaustive in detail, rich in its exposi- 
tion of the latest and most uniformly successful methods in operating, 
and modern throughout in its treatment of each branch of surgical 
work, particularly that of abdominal surgery, this book easily ranks 
among the very foremost works in its particular field. 

45 



Carpenter on THE MICR OSCOPE 

AND ITS REVELATIONS 

EIGHTH EVITIOJV 

Edited by W. H. Dallin^cr, D.Sc, D.C.L, F.R.S. 



With 23 Plates and nearly 900 Engravings 



OCTAVO. 1181 PAGES. CLOTH, $8.00; HALF MOROCCO, $9.00 



*** Eight of the chapters have been entirely rewritten and the text 
throughout reconstructed, enlarged, and revised with the aid and advice 
of E* M. Nelson, ex-President of The Royal Microscopical Society; 
Arthur Bolles Lee, author of "The Microtomist's Vade Mecum"; Dr. E* 
Crookshank, the well-known Bacteriologist; Prof* T* Bonney, F.R*S.; 
W* J. Pope, F*I*C*, F*C.S., etc., Chemist to the Goldsmith's Technical 
Institute ; Prof* A* W* Bennett, Lecturer on Botany at St. Thomas' Hos- 
pital ; and F. Jeffrey Bell, Professor of Comparative Anatomy and Zoology, 
King's College, London* 

*#*A thorough and complete revision of the entire text has 
been made ; eight chapters have been entirely reconstructed, and 
everything of importance to Microscopy which has transpired in 
the interval has been noted* This applies to the theory of the 
Microscope as well as to its use* Many new illustrations have 
been included and it has been very materially increased in size. 



CARPENTER" is the only complete and exhaustive modern work on 

the Science of Microscopy 

46 



Diseases of ike Digestive Tract 

Their Special Pathology f Diagnosis, and Treatment. With 
Sections on Anatomy and Physiology, Analysis of Stomach 
and Intestinal Contents, Secretions, Feces, Urine, Bacteria, 
Parasites, etc*, Su rgery, Dietetics, Diseases of the Rectum, etc* 

AN EXHAUSTIVE SYSTEMATIC TREATISE 

By JOHN C. HEMMETER, M.D. 

Professor in the Medical Department of the University of Maryland ; Consultant to the University Hospital and 

Director of the Clinical Laboratory, etc.? formerly Clinical Professor of Medicine 

at the Baltimore Medical College, etc. 



DISEASES OF THE STOMACH. Third Edition. 

With 15 Plates and 41 other Illustrations, some of which 
are printed in Colors. Octavo. 894 pages. 

Cloth, S6.00 ; Sheep, 37.00 

DISEASES OF THE INTESTINES. Two Volumes. 

With 19 Plates and no other Illustrations, some of which 
are printed in Colors. Octavo. 142 1 pages. 

Vol. I. Anatomy, Physiologv, Pathology, Diagnosis, Thera- 
peutics, Intestinal Clinic, etc. Cloth, $5.00; Sheep, $6.00 

Vol. II. Appendicitis, Occlusions, Intestinal Surgery, En- 
teroptosis, Infectious Granulomata, Neuroses, Parasites, Dis- 
eases of the Rectum, etc. Cloth, §5.00; Sheep, $6.00 

*.£* These books form a complete treatise or Diseases of the Digestive Tract. 
The subject is covered thoroughly and systematically by an author of well-known 
reputation and ability. The results of recent investigation, by which so much 
progress has been made in the Pathology, Diagnosis, and Medical and Surgical 
Treatment of disorders of the intestinal tract, make their issue at this time of 
special importance. They are handsomely illustrated, exhaustive, and written 
for the general practitioner, taking into special consideration American habits of 
living, diet, and climate. 

" We wish to express unqualified approval of the tendency which is shown to emphasize the 
simple and more practical methods of diagnosis." — Neio York Medical Journal, Review of " Dis- 
eases of the Stomach." 



DESCRIPTIVE CIRCULAR UPON APPLICATION 

47 



IN PRESS 



Edgar's Obstetrics 



A NEW TEXT-BOOK 



By J. CLIFTON EDGAR, M.D. 

Professor of Obstetrics, Medical Department of Cornell University, New York City; Physician to Mothers' and 
Babies' Hospital and to the Emergency Hospital, etc. 



Octavo, about J000 Pages; 900 Illustrations 



The Illustrations in Edgar's Obstetrics surpass in number, in artistic 
beauty and in practical worth those in any book of similar character. They are 
largely from original sources. Those which follow other works have been 
redrawn with modifications so that the entire series is new. All have been drawn 
by artists of long experience in this department of medical illustration, and 
whenever of advantage to do so are reproduced at a stated scale. 

No attempt has been made at display. When a small cut serves every pur- 
pose drawings are not reproduced to occupy a large space; when black and white 
are equally expressive an elaborate colored plate has not been used. So far 
as possible, cuts have been inserted in the text where they are wanted and where 
the eye catches them at the place the text explains them. Relative importance 
has determined the selection, the size, and the character of each figure. There 
are many explanatory diagrams which add greatly to the teaching values of the 
pictures. The aim of author, artist, and publisher has been to make a series of 
pictures useful to the student and reader, and no time, labor, or money has 
been spared to gain this end. The lack of uniformity in quality and failure to 
observe scale — the great faults in books on this subject — have been kept constantly 
in mind, and every endeavor has been made to avoid similar defects. 

The Text has been prepared with great care. The author's extensive 
experience in hospital and private practice and as a teacher,, his cosmopolitan 
knowledge of literature and methods, and an excellent judgment based upon all 
these fit him specially to prepare what must be a standard work for both. students 
and physicians. 

In the text as in the illustrating, uniformity and consistency have been kept 
constantly in view. The subjects of monstrosities and malformations, for example, 
do not take up space which could be better used for more practical and useful 
matters, though these topics like others of their class receive due consideration 
and are illustrated by a very complete series of small figures. Nothing of 
importance remains unsaid, and the relative value of each subject has been care- 
fully planned out and fixed by deliberate thought. The author's reputation is 
sufficient guarantee of the merit of this book; the publishers, however, ask a 
comparison with other works, with confidence that this will be found the most 
useful. 

43 



LIBRARY OF CONGRESS 




